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

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on November 13, 2019 by an out-of-network (OON) provider.

You asked the Plan to pay for the unlisted molecular pathology procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for an unlisted molecular pathology procedure provided on November 13, 2019 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 28, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you had to go to the emergency room twice within 24 hours and feel that the second copayment should be waived. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $100 copayment for emergency care. 

You have been asked to pay a $100 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on March 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the impacted tooth removal (D7240) and non-intravenous sedation (D9248).

You asked the Plan to pre-approve the impacted tooth removal (D7240) and non-intravenous sedation (D9248). You say that your dental issues are affected by your health and your health is affected by your dental problems. You say that all you want to be able to get is dentures and you hope that removing the remaining teeth will be approved. The Plan denied your request. The Plan says the services are not covered 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 pre-approve the impacted tooth removal (D7240) and non-intravenous sedation (D9248).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007).
You asked the Plan to pre-approve an extra heavy-duty wheelchair. You say that you are not able to walk around, and you are falling everywhere. The Plan denied your request. The Plan says you have already been provided with a motorized scooter and the requested wheelchair is considered a duplicate item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a motorized scooter (K0801). This item serves the same purpose as an extra heavy-duty wheelchair. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty wheelchair (K0007).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder decompression services.

You asked the Plan to pre-approve the requested services. You say that the enrollee had physician led exercises and injections with no improvements. The Plan denied your request. The Plan says this procedure has not been shown to improve health outcomes compared to alternative, conservative treatments.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

In this case, the CPT Code Manual definition of code 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed.

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 requested services. Our physician reviewer found that the enrollee is being treated for pain in the left shoulder. She presents with complaints of left shoulder pain, especially when she tries to do activities. An exam reveals decreased range of motion of the left shoulder with forward elevation to about 90 and abduction to about 80, external rotation is limited. When the shoulder is passively moved, there was no adhesive capsulitis. Her biceps were intact. She is able to hold resistance when the rotator cuff is stressed. She had a very positive impingement test with abduction, internal rotation, and adduction internal rotation. She has some pain with biceps elevation test. Detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. There are limited large-scale, long-term references showing the safety and efficacy of the requested decompression surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for shoulder decompression is not indicated and 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve shoulder decompression services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on April 26, 2021, by an OON provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that it is not fair for you to
pay the difference between the in-network and OON fees. The Plan denied your request. The Plan says the
treating provider is OON. The Plan also says that OON providers are allowed to balance bill you for the
difference between their billed amount and the Plan's paid amount.

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, you are responsible for the difference
between the billed amount and allowed amount for dental services received OON. Therefore, we decided that
the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on
April 26, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a PET scan and to waive the coinsurance for contrast provided on April 21, 2021.

You asked the Plan to waive the copayment for a PET scan and to waive the coinsurance for contrast. You say that your benefits state that you should only owe a $175 copayment for the PET scan. You were not informed that you would also owe coinsurance on the contrast and feel that the charges are too high. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.

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 diagnostic radiology. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You received a PET scan on April 21, 2021. Therefore, you are responsible to pay the $175 copayment. 

You received contrast on April 21, 2021. The total allowed amount is $5,198.40 and 20% of that is $1,039.68. 

The total amount you owe is: $1,214.68. 

You have been asked to pay the total amount of $1,214.68 a PET scan and contrast. A PET scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Contrast falls within the Medicare Part B prescription drugs 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 a PET scan and to waive the coinsurance for contrast provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 3) and pontic (D6245) provided on May 11, 2021.
You asked the Plan to pay for the dental services. You say that you have not been to the dentist in over 20 years. You say that you did not realize that this dentist was out of network. You also say that you have been with him so long that you did not want to have to change dentists. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services you receive out of network 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network are not among those covered under this benefit. Additionally, the record shows that you were advised by a plan representative that there are no out of network benefits. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6740 x 3) and pontic (D6245) provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional resin-based composites provided on March 30,
2021.

You asked the Plan to pay for the additional resin-based composites. You say that the Plan provides $2,500
maximum coverage per year and the billed charges are well below the maximum. The Plan denied your
request. The Plan says reimbursement has already been issued for two fillings.

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, you also have a maximum benefit of
two amalgam or resin-based composites per calendar year. The Plan paid for two resin-based composites
provided on March 30, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have
to pay for the additional resin-based composites provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra-wide, heavy-duty hospital bed (E0303).

You asked the Plan to pre-approve an extra-wide, heavy-duty hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says you do not meet the weight requirements for this item.

The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an extra-wide, heavy-duty hospital bed have not been met. Specifically, you do not meet the weight requirement for the requested DME. Therefore, we decided that the Plan does not have to pre-approve an extra-wide, heavy-duty hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5225), mandibular partial denture (D5226), simple extractions (D7140), surgical extractions (D7210), and adjunctive procedure (D9999) provided on February 10, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the maxillary partial denture, mandibular partial denture, extractions, and adjunctive procedure. You say that you were not aware that this treating provider was not in-network with your plan. The Plan denied your request. The Plan says this treating provider opted out of Medicare effective September 21, 2015, to September 21, 2021. The Plan also says that if you use a provider that has opted out of Medicare you will not receive reimbursement.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture (D5225), mandibular partial denture (D5226), simple extractions (D7140), surgical extractions (D7210), and adjunctive procedure (D9999) provided on February 10, 2021 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the skin biopsy procedure you had at an
outpatient hospital facility on March 8, 2021.

You asked the Plan to reduce the copayment for the skin biopsy procedure. You say that you believe your
copayment should only be a $35 copayment for visits with a specialist. The Plan denied your request. The Plan
says you were charged this copayment correctly. The Plan says that because the allowed amount for this
procedure ($303.33) is less than your copayment obligation, you are responsible for the full allowed amount.
The Plan says that these services were performed at an outpatient hospital facility, not a specialist's office, so
the copayment applied 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 $325
copayment for surgery or other services at an outpatient hospital facility.

You have been asked to pay a $325 copayment for the skin biopsy procedure. The skin biopsy procedure falls
within the surgery or other services 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 reduce the copayment for the skin biopsy procedure you had at an outpatient hospital facility on March 8,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a deep purple accent color for a power wheelchair (K0108).

You asked the Plan to pre-approve a deep purple accent color for a power wheelchair. You say that the item is medically necessary. The Plan denied your request. The Plan says a custom color does not serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a deep purple accent color for a power wheelchair (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and cone beam computed tomography (CT) capture and interpretation (D0364) provided on May 17, 2021.

You asked the Plan to pay for the dental services. You say that your dentist referred you to an endodontist. You say that he did not even look at your teeth. You say that you were then sent to your internist to be referred to neurology. You say that you have paid $225 so far. You also say that you need help with this claim. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan also says cone beam CT is not listed as a covered service either.

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 services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and cone beam computed tomography (CT) capture and interpretation (D0364) provided on May 17, 2021.
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 enrollee is stable and suitable for transfer to an LTACH and cannot be adequately cared for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting.

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 that the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended 

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) receiver (code K0554), and a 12-month supply of Dexcom G6 supply kits (code K0553).
You asked the Plan to pre-approve a Dexcom G6 and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the member is only taking two insulin shots daily.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) receiver (code K0554), and a 12-month supply of Dexcom G6 supply kits (code K0553).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections provided on October 27, 2020.

You asked the Plan to pay for the vitamin injections. You say that the medical records are attached, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says a nutria-pharmaceutical blend was administered; therefore, each component of the blend cannot be billed separately.

The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, NOC code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vitamin injections have not been met. Specifically, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the NOC code J7999. As this compounded drug was not billed properly, payment cannot be made. Therefore, we decided that the Plan does not have to pay for the vitamin injections provided on October 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on April 18, 2021.
You asked the Plan to pay for the services provided. You say that the claim was billed with an appropriate
diagnosis code. The Plan denied your request. The Plan says the claim denied correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We looked at the file and the rules. We find that CPT Code 93042 is payable when billed with code 93010
when billed with an appropriate modifier. The billed claim does not indicate a payable modifier was used in
this case. Based on this information, we decided the Medicare rules for coverage have not been met.
We looked at the file and the rules. We find that CPT codes 93010 and 99285 were billed with a diagnosis code
of T38.0X5A. We find that this diagnosis code falls under the code title poisoning by adverse effect of and
underdosing of hormones and their synthetic substitutes and antagonists, not elsewhere classified. There is a
"use additional code" note at the etiology code and a code first note at the manifestation code. This means that
the codes are never permitted to be used as first listed or principal diagnosis codes. Based on this information,
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the emergency room services provided on April 18, 2021.