Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided on March 10, 2021.
You asked the Plan to pay for the pulp vitality tests. You say that you would like this claim to be reprocessed and covered at 50% of the allowed amount. The Plan denied your request. The Plan says this service is 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, 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 pulp vitality tests (D0460) provided on March 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis (74177) and CT thorax.
You asked the Plan to pre-approve computed tomography, abdomen and pelvis; with contrast material(s) (74177) and computed tomography, thorax, diagnostic; with contrast material(s) (71260). You say that the enrollee needs these CTs. The Plan denied your request. The Plan says guidelines do not support surveillance imaging.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 computed tomography, abdomen and pelvis; with contrast material(s) (74177) and computed tomography, thorax, diagnostic; with contrast material(s) (71260). Our reviewer says that the CTs are not medically reasonable and necessary.
Our physician reviewer found surveillance imaging is not recommended by the National Comprehensive Cancer Network (NCCN) Guidelines. There are no signs or symptoms to suggest recurrence. The service is not reasonable or medically 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 computed tomography, abdomen and pelvis; with contrast material(s) (74177) and computed tomography, thorax, diagnostic; with contrast material(s) (71260) have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT), abdomen and pelvis (74177) and CT thorax.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on May 11, 2021.
You asked the Plan to pay for the incomplete endodontic therapy. You say that when you contacted the Plan on May 5, 2021, you were advised that a root canal would be covered with an out-of-network dentist. You also say that the provider advised the root canal could not be completed, and you believe the amount should be paid. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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. The record shows that you were advised by a Plan representative on May 5, 2021 that root canals are covered under the Plan. The Plan contacted the provider and confirmed that a root canal was not performed, and that you would not be billed for a root canal. You were billed for an
incomplete root canal treatment, which is clearly excluded from coverage. Therefore, we decided that the Plan does not have to pay for the incomplete endodontic therapy (D3332) provided on May 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage (A0170).

You asked the Plan to pre-approve additional mileage. You say that you need transportation and additional mileage to get to an appointment. The Plan denied your request. The Plan says your benefit only allows 60 one-way trips with each one-way trip not exceeding 75 miles of driving distance.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the driving distance for a one-way trip is within 75 miles.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the provider is located 96 miles away from your residence. The Plan only covers distances up to 75 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings (D4341 x4).
You asked the Plan to pre-approve the scalings and planings. You say that you need the scalings and planings to be approved for coverage. The Plan denied your request. The Plan says this service is 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, 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 four periodontal scalings and root planings (D4341 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax coded as 71250 provided April 1, 2021.

You asked the Plan to pay for the CT scan of the thorax. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is a duplicate of a claim already paid.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We find that CPT code 71250 is not supported in the medical record. Specifically, the record indicates that this is an exact duplicate of another claim that has been processed and paid. In this case, the medical records do not support that these services were performed and are not in fact a duplicate of the claim that was already paid Based on this information, we decided that Medicare rules for coverage of the CT scan of the thorax have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the thorax coded as 71250 provided April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on February 24, 2021.

You asked the Plan to pay for the outpatient hospital services. 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. CPT code 77049 has a status indicator of "B" and is not recognized by OPPS when submitted on an outpatient hospital Part B bill type 13X. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on February 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound exam of the pelvis (76856), vascular study (93975), and the transvaginal ultrasound (76830) rendered by the out-of-network (OON) provider on May 18, 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 ultrasound exam of the pelvis (76856), vascular study (93975), and the transvaginal ultrasound (76830) rendered by the out-of-network (OON) provider on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) provided on
February 15, 2021.
You asked the Plan to pay for the adjunctive pre-diagnostic test. You say that when you signed up for this
insurance plan you made sure to verify if there would be any additional expenses that you would have to cover,
and were informed that there would be no cost for the dental care you needed. The Plan denied your request.
The Plan says this service is not covered under your plan.
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
adjunctive pre-diagnostic test (D0431) provided on February 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on February 23, 2021.

You asked the Plan to pay for code 99291. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99291.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that the first 30-74 minutes was spent providing services to the enrollee. The progress note for February 23, 2021 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of code 99291. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services represented by code 99291 provided on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 2), the pre-diagnostic tests
(D0431), the localized delivery of antimicrobial agents (D4381 x 2), and the drugs or medicaments for home
use (D9630 x 2) provided on April 29, 2021.
You asked the Plan to pay for the dental services. You say that you needed these services. You also say that
you cannot afford to pay this bill. The Plan denied your request. The Plan says gingival irrigation is not listed
as a covered service. The Plan says that pre-diagnostic test is not listed as a covered service. The Plan says that
localized delivery of antimicrobial agents is not listed as a covered service. The Plan also says that drugs or
medicaments for home use are not listed as covered services 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
gingival irrigation (D4921 x 2), the pre-diagnostic tests (D0431), the localized delivery of antimicrobial agents
(D4381 x 2), and the drugs or medicaments for home use (D9630 x 2) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete maxillary denture (D5110), complete
mandibular denture (D5120), and adjunctive procedures (D9999) provided from November 10, 2020, to
December 7, 2020.

You asked the Plan to pre-approve the complete maxillary denture, complete mandibular denture, and
adjunctive procedures. You say that after your surgery, your old dentures no longer fit. You also say that the
new dentures were a medical necessity and you believe these services should be covered. The Plan denied your
request. The Plan says these services are not covered according to your plan of benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the complete maxillary
denture (D5110), complete mandibular denture (D5120), and adjunctive procedures (D9999) provided from
November 10, 2020, to December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 27, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you asked the provider about any payment and they told you that you would owe nothing. You also say that you were unaware these services were only allowed once every three years. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.

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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on April 25, 2019 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on April 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve personal care services (T1019).
You asked the Plan to pre-approve the personal care services. You say that you are handicapped and need help doing your laundry. The Plan denied your request. The Plan says you do not meet the criteria for coverage of personal care services.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of personal care services have not been met. Specifically, the record does not indicate that you have
support from your health care provider for the requested services. Therefore, we decided that the Plan does not have to pre-approve personal care services (T1019).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure you had at an ambulatory surgery center on April 14, 2021.
You asked the Plan to waive the copayment for the injection procedure. You say that you think it is ridiculous that your copayment is higher than what the Plan paid. You also stated that you do not believe this procedure should be considered a surgery. 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 $250 copayment for surgery or procedures at an ambulatory surgery center. You have been asked to pay a $250 copayment for the injection procedure. This copayment applies to all surgeries and procedures at an ambulatory surgery center. 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 injection procedure you had at an ambulatory surgery center on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on March 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient hospital services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 outpatient hospital services provided on March
10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on March 23, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the wound care. 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 the wound care provided on March 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.

You asked the Plan to pre-approve the requested services. You say that you are in pain and have tried all other treatment. The Plan denied your request. The Plan says the clinical effectiveness of a genicular nerve block in the setting of knee osteoarthritis has not been demonstrated in peer-reviewed literature.

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 requested services. Our physician reviewer found that you have chronic bilateral knee pain. You have been treated with Cymbalta, and Acetaminophen, have had cortisone injections which provided relief for approximately 3 months, and have had viscosupplementation therapy with Euflexxa and Synvisc. Genicular nerve blocks and genicular nerve ablation are considered investigational for the treatment of chronic knee pain. Therefore, the requested genicular nerve ablations are not reasonable and medically 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 a genicular nerve block.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda) for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary for treatment of metastatic gastric cancer. The Plan denied your request. The Plan says this does not meet the criteria sufficiently for approval.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Pembrolizumab is not FDA approved for the first line treatment of metastatic gastric cancer. Two prior lines of therapy are recommended. For dMMR tumors, approval is for tumors that have progressed following prior treatment and have no satisfactory alternate treatment options. The enrollee does not fit either approval, and the use of this drug is not supported for off-label use by the major drug compendia or the medical literature. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab (Keytruda) for the enrollee.