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

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 14, 2021.
You asked the Plan to pay for the dental services. You say that you went to get your teeth cleaned. You say that you were told the provider was in network. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says dental services received 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. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided on February 12, 2021.
You asked the Plan to pay for the CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 70450 is a column II code to column I code 70460. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft (D4263) provided on May 6, 2021.
You asked the Plan to pay for the dental service. You say that you received a bone graft and extraction on the same day. You say that the bone graft was denied. You say that you feel that if they were performed on different days, they would have both been covered. The Plan denied your request. The Plan says the bone graft is not covered when performed in an extraction site.
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 bone graft performed where an extraction was done is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone graft (D4263) provided on May 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99282) provided on September 28, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as you left the emergency room without being seen. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 a $65 copayment for Emergency care.
You have been asked to pay a $65 copayment for an emergency room visit. The record indicates that you were seen in the ER, checked in, and documented as leaving against medical advice. the emergency room visit 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 an emergency room visit (99282) provided on September 28, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial upper denture (D5820) provided on September 13, 2021.

You asked the Plan to pay for the interim denture. You say that you thought these services would be covered, and you cannot afford this bill. The Plan denied your request. The Plan says this item is not covered by your dental benefit.

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 interim partial upper denture (D5820) provided on September 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged outpatient service (99354) provided on August 17, 2021.
You asked the Plan to pay for prolonged outpatient service 99354. You say that you are appealing with records to support the medical necessity of this code. The Plan denied your request. The Plan says the denial of
payment for this service is correct, because code 99354 has a procedure-to-procedure (PTP) edit of 0 with code 90836 so it not separately payable.
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, we have confirmed that code 99354 is a column II code to column I code 90836. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for prolonged outpatient service (99354) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on September 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says services must be provided by an in-network 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 dental services provided on September 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).
You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says this item used in a BiPaP mode is not a covered item.
The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as not reasonable and necessary. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician services (99232) provided December 6, 2020.
You asked the Plan to pay for the physician services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the claim cannot be paid as billed.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan's denial notice did not fully articulate the reason for the denial. The guidelines used to determine the services were not covered were not provided for review. Therefore, we decided that the Plan has to pay for physician services (99232) provided December 6, 2020.
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 a complete upper denture (D5110), reline of complete upper denture (D5750), tissue conditioning (D5850), and a partial lower denture (D5212).

You asked the Plan to pre-approve the dental services. You say that you were promised dentures. You also say that you were denied dentures. The Plan denied your request. The Plan says dentures are not listed as covered services. The Plan says that reline of denture is not listed as a covered service. The Plan also says tissue conditioning is not listed as a covered 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dentures and related services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110), reline of complete upper denture (D5750), tissue conditioning (D5850), and a partial lower denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON cardiology visits. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-network.
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 cardiology visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 gene analysis.
You asked the Plan to pre-approve F5 gene analysis. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested services.
The Plan must follow Medicare rules. Medicare rules say that testing for the F5 gene is only covered for enrollees who are pregnant. We looked at the file and Medicare rules. Review of the file does not support that the enrollee is pregnant. Based on this information, we decided that Medicare rules for coverage of F5 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve F5 gene analysis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).

You asked the Plan to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). You say that the procedure is the most appropriate treatment to achieve sustainable long-term relief. You say that clinical evidence demonstrates the procedure is safe, efficacious, and durable for selected patients. The Plan denied your request. The Plan says the procedure is considered experimental and not covered.

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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer says that intraosseous nerve ablation remains experimental. 

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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth # 30.

You asked the Plan to pre-approve the dental service. You say that the requested service is necessary. The Plan denied your request. The Plan says pontic is not listed as a covered 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested pontic is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for tooth # 30.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee brace (L1845).

You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied
your request. The Plan says there is no record of recent injury or surgery or objective evidence of instability.

The Plan must follow Medicare rules. Medicare rules say that a knee orthosis, with an adjustable flexion and
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) or when knee
instability is documented by examination of the beneficiary and objective description of joint laxity.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a knee brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a
knee brace (L1845).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve root canals (D3320) for teeth # 12 and 20.

You asked the Plan to pre-approve the dental services. You say that the root canals are medically necessary. The Plan denied your request. The Plan says root canals are not 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 root canals are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve root canals (D3320) for teeth # 12 and 20.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you are not receiving any help from your current physician. The Plan denied your request. The Plan says the provider is out-of-network.

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 the office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device (E0601).

You asked the Plan to pre-approve a replacement CPAP.. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not medically necessary because your provider has not documented loss, theft, or irreparable damage of your current device, which was provided less than five years ago.

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 CPAP device. This device serves the same purpose as a replacement CPAP.. Records indicate you obtained your current device less than five years ago and there is documentation of loss, theft, or irreparable dame to your current device. Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for coverage for a pneumatic compression device have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that you had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography coded 70544 provided on August 24, 2021.

You asked the Plan to pay for the magnetic resonance angiography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a separately payable.

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, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography coded 70544 provided on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the interspinous spacer placement is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-covered.

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 interspinous spacer placement. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found this procedure is still considered experimental. More research is needed to show safety and efficacy. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22870, 22869).