Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the epidural injection procedures you had
on March 17, 2021, and April 20, 2021, at an ambulatory surgery center.

You asked the Plan to waive the copayments for the epidural injection procedures. You say that these were
injections and should not be considered surgery. The Plan denied your request. The Plan says you were charged
these copayments correctly.

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 a $200
copayment for outpatient surgery in an ambulatory surgery center.

You have been asked to pay a $200 copayment for the epidural injection procedures. Epidural injections are
considered surgical procedures, so the epidural injection procedures fall within the outpatient surgery in an
ambulatory surgery center benefit category. 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 copayments for the
epidural injection procedures you had on March 17, 2021, and April 20, 2021, at an ambulatory surgery center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on May 4,
2021 and June 4, 2021.

You asked the Plan to pay for electrical stimulator supplies. You say that you are appealing this denial. The
Plan denied your request. The Plan says the denial of payment for these supplies is correct, because no medical
records were submitted to support diagnosis codes specifying the laterality of the condition and it is not
appropriate to report unspecified and left/right diagnosis codes for the same code.

The Plan must follow Medicare rules. Medicare rules say that the supplier must furnish to the Plan sufficient
information to determine whether payment is due and the amount of payment for a claim.

We looked at the file and Medicare rules. You did not submit medical records to the Plan to support the diagnosis codes billed on these claims. Without supporting records, you have not furnished sufficient information to justify payment of these claims as they have been billed. Based on this information, we decided that Medicare rules for coverage of electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies (A4595) provided on May 4, 2021 and June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, problem focused (D0140)
provided May 25, 2021.
You asked the Plan to pay for the limited oral exam. You say that you got a second opinion about a root canal.
You cannot afford the cost at this time. The Plan denied your request. The Plan says you have exceeded the
frequency limit for this service.
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. The Plan covers the limited
oral exam once per plan year.
We looked at the file and Medicare rules. A limited oral exam was previously covered on January 21, 2021.
Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has
been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation,
problem focused (D0140) provided May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan.
You asked the Plan to pre-approve the CT scan. You say that your doctor feels that it is a necessary procedure. The Plan denied your request. The Plan says the records do not show why other tests cannot be done first.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. The file shows that a CT scan of the abdomen and pelvis was requested. 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 CT scan. Our physician reviewer found that you have a history of hypothyroidism, migraines, and reported fevers. There is no specific clinical rationale for the requested CT scan. There are no reported physical exams or lab abnormalities. Therefore, the requested CT scan is not medically reasonable or necessary. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 12.

You asked the Plan to pre-approve a crown. You say that you disagree with the denial for the deep cleaning and the crown. You say that you are in so much pain and need the services. The Plan denied your request. The Plan says the crown is not medically necessary.

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. The Plan covers a crown when the services are medically necessary and reasonable. 

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 crown. Our reviewer says that the crown is not medically necessary. Our physician reviewer found the provided dental record and radiographs indicate the presence of a crown on tooth # 12. The reviewer found that the radiograph does not show a defective crown. The reviewer found that there was not a narrative specifying a reason for the need of a replacement crown. Therefore, the reviewer found that the requested crown for tooth # 12 is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Specifically, the file does not show that the current crown is defective and needs to be replaced. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 12.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation.
You asked the Plan to pre-approve Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment;
initial, including cortical mapping, motor threshold determination, delivery and management (90867),
Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and
management, per session (90868) and Therapeutic repetitive transcranial magnetic stimulation (TMS)
treatment; subsequent motor threshold re-determination with delivery and management (90869). You say that
the enrollee meets criteria for this procedure. The Plan denied your request. The Plan says TMS is not 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 Therapeutic repetitive transcranial
magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination,
delivery and management (90867), Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment;
subsequent delivery and management, per session (90868) and Therapeutic repetitive transcranial magnetic
stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management
(90869). Our reviewer says that the requested services are not considered medically reasonable and necessary
in this case. Our physician reviewer found This patient does possess the diagnosis as noted above. She had
been tried on pharmacologic agents from different categories for which she has had very little improvement.
There is no mention of the patient desiring electroconvulsive treatment or a course of psychotherapy. Based on
the records provided this patient does not meet the criteria or treatment with Repetitive Transcranial Magnetic
(rTMS).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment;
initial, including cortical mapping, motor threshold determination, delivery and management (90867),
Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and
management, per session (90868) and Therapeutic repetitive transcranial magnetic stimulation (TMS)
treatment; subsequent motor threshold re-determination with delivery and management (90869) have not been
met. Therefore, we decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain fused to high noble alloys (D6066) provided April 28, 2021.

You asked the Plan to pay for the implant supported porcelain fused to high noble alloys. You say that you chose a more efficient and less expensive service. The Plan denied your request. The Plan says you have been provided a one-time exception to have the claims from this date of service reprocessed as in-network, however, this service is not covered under your benefits.

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 pay for the implant supported porcelain fused to high noble alloys (D6066) provided April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the excision of skin of nail fold services provided by an out-of-network (OON) provider on February 4, 2021.
You asked the Plan to waive the coinsurance for these OON services. You say that you were informed that this was considered an in-network procedure. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
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 50% coinsurance for podiatry services received out-of-network.
You have been asked to pay 50% coinsurance for these OON podiatry services. These OON podiatry services received fall within the out-of-network podiatry benefit category. 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 coinsurance for the excision of skin of nail fold services provided by an out-of-network (OON) provider on February 4, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound debridement procedure you had
at an outpatient hospital facility on May 5, 2021.

You asked the Plan to waive the copayment for the wound debridement procedure. You say that if you had
been told prior to the service that your copayment would be $175, you would have declined the services. The
Plan denied your request. The Plan says you were charged this copayment correctly.

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 a $175
copayment for surgery or other services provided at an outpatient hospital facility.

You have been asked to pay a $175 copayment for the wound debridement procedure. The wound debridement
procedure falls within the surgery or other services provided at an outpatient hospital facility benefit category.
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 copayment for the wound debridement procedure you had at an outpatient
hospital facility on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-insulin drug infusion pump supplies provided from
November 18, 2020, to December 9, 2020.
You asked the Plan to pay for the non-insulin drug infusion pump supplies. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the items provided are not
supported by the documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file
shows that the documentation submitted did not include an itemized shipping/billing invoice to indicate the
specific supplies provided. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pay for the non-insulin
drug infusion pump supplies provided from November 18, 2020, to December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of cartilage ring at spinal disc using fluoroscopic guidance (22526) provided on February 4, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the removal of cartilage ring at spinal disc using fluoroscopic guidance. You say that this request is medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the removal of cartilage ring at spinal disc using fluoroscopic guidance (22526) provided on February 4, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on June 7, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on
June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after October 7, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 84-year-old female with gastric ulcer and anemia. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. Finally, you do 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderation sedation service 99153 provided on January 20, 2021.

You asked the Plan to pay for 99153. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code may not be paid if furnished to a hospital inpatient or hospital outpatient.

The Plan must follow Medicare rules. Medicare rules say that carriers may not pay technical component (TC) only codes furnished to hospital outpatients.

We looked at the file and Medicare rules. The records show that the code was billed without a modifier, meaning that you are requesting payment of the technical component and the professional component. However, the place of service billed on this claim was an outpatient hospital. This means that the hospital is paid for the technical component of the service. Based on this information, we decided that Medicare rules for coverage of 99153 have not been met. Therefore, we decided that the Plan does not have to pay for moderation sedation service 99153 provided on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the swallowing function x-ray rendered on May 4, 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 diagnosis code is not valid.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary diagnosis code.

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 swallowing function x-ray rendered on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
You asked the Plan to pre-approve an Intracept procedure. You say that this is a necessary and covered service. The Plan denied your request. The Plan says this is experimental.
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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure for low back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752, C9753).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), intraoral - complete series of radiographic images (D0210), and comprehensive oral evaluation - new or established patient (D0150) provided May 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the dental cleaning, intraoral x-rays and comprehensive oral exam. You say that you called ahead to verify the copayments for services and do not understand why you are responsible for the full amount. The Plan denied your request. The Plan says the services were provided OON, and therefore are not covered.

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. The Plan covers the dental cleaning, intraoral x-rays and comprehensive oral exam when the services are provided in-network. 

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning, intraoral x-rays and comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), intraoral - complete series of radiographic images (D0210), and comprehensive oral evaluation - new or established patient (D0150) provided May 5, 2021 by an out-of-network (OON) provider.