Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share liability for the sleep study (95810) provided on May 16, 2021.
You asked the Plan to waive the cost share liability. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an in-network yearly deductible of $425. Additionally, you pay a 20% coinsurance per day, per provider, for diagnostic procedures and tests. You have been asked to pay $507 which includes a $413.54 deductible applied as you had not previously met the yearly deductible. Additionally, this amount includes a $93.86 coinsurance. The coinsurance has been calculated as (the Plan allowed amount of $882.84-$413.54 deductible=$469.30 x 20% coinsurance=$93.86). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share liability for the sleep study (95810) provided on May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retreatment of previous anterior root canal therapy (D3346) and a retreatment of previous premolar root canal therapy (D3347).
You asked the Plan to pre-approve the retreatments of previous root canal therapies. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retreatment of previous anterior root canal therapy (D3346) and a retreatment of previous premolar root canal therapy (D3347).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81403, 81405, & 81406) provided January 4, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81401, 81403, 81405, & 81406 are not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81401, 81403, 81405, & 81406) provided January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated abutments (D6056 x 2) and the abutment supported crowns (D6058 x 2) provided on May 6, 2021.
You asked the Plan to pay for the dental services. You say that you are retired and on a fixed income. You say that this amount is difficult to pay. The Plan denied your request. The Plan says prefabricated abutments are not listed as covered services. The Plan says that abutment supported crowns are not listed as covered services either. The Plan also says there is no record of you calling the plan to verify benefits or provided eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the prefabricated abutments and abutment supported crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated abutments (D6056 x 2) and the abutment supported crowns (D6058 x 2) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the global fee urgent care center services represented by code S9083 provided on April 17, 2021.
You asked the Plan to pay for code S9083. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code S9083 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the global fee urgent care center services represented by code S9083 provided on April 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on December 31, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, and then there is no Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 31, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on December 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xiidra.
You asked the Plan to pre-approve Xiidra. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xiidra.
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that the item is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility deficit that impairs their participation in MRADLs, the patient's condition cannot be ameliorated by a walker, cane or manual wheelchair, and the patient is capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says that the item is medically necessary. Our physician reviewer found based on the medical records provided there is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. You reportedly have a scooter which is ten years old, but records indicate you cannot reach counter tops from your scooter. The records indicate that you can safely operate a power mobility device and that your home setting is adequate for the power mobility device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have been met. Therefore, we decided that the Plan has to pre-approve a power wheelchair.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-precision attachment abutments (D6052) for teeth # 22 and 27.
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says semi-precision attachment abutments are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the semi-precision attachment abutments are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve semi-precision attachment abutments (D6052) for teeth # 22 and 27.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
You asked the Plan to pre-approve a MILD procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a MILD procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MILD procedure remains experimental. More research is needed to show safety and efficacy of the procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression (MILD) procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous spacer (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex Superion Interspinous spacer. You say that this would improve the enrollee's quality of life. The Plan denied your request. The Plan says this is not indicated for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the insertion of a Vertiflex Superion Interspinous spacer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show that it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of a Vertiflex Superion Interspinous spacer have not been met.
Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous spacer (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232) provided March 15, 2021.
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code 99232 is not supported in the medical record. Specifically, this service was rendered within the 90-day global surgery period for a major surgical procedure (28150). An appropriate modifier to denote a distinct and unrelated service was not billed with this claim. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99232) provided March 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on November 10, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 10, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hetlioz.
You asked the Plan to pre-approve Hetlioz. You say that the medication is necessary. The Plan denied your request. The Plan says your plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hetlioz.
Benefits for Hetlioz may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fillings (D2392 x 2), core build up (D2950), a porcelain crown (D2740), and partial upper denture (D5213).
You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay for these services. You also say that the services are necessary. The Plan denied your request. The Plan says fillings, core build up, porcelain crown, and partial upper denture are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fillings (D2392 x 2), core build up (D2950), a porcelain crown (D2740), and partial upper denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aid repair provided on March 25, 2021.
You asked the Plan to reimburse you for hearing aid repair. You say that you had to have a replacement hearing aid and not a repair of the hearing aid. The Plan denied your request. The Plan says hearing aid repairs are not a covered benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan's hearing aid benefit does not provide coverage for hearing aid repairs. Therefore, we decided that the Plan does not have to reimburse you for hearing aid repair provided on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not covered under your benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. A core buildup, including any pins when required (D2950) is considered to be a restorative service which are not covered under your plan. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow biopsy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a bone marrow biopsy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a bone marrow biopsy to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the venous catheter insertion rendered on March 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the venous catheter insertion rendered on March 9, 2021.