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

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 28, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that you believe the doctor should be paid for the x-rays he took. The Plan denied your request. The Plan says the frequency limit for this service has been exceeded.  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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on March 23, 2021 and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on August 17, 2021 by an out-of-network (OON) provider.  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 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 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 office visit provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the venous catheter replacement and fluoroscopic guidance provided by an out-of-network provider on September 20, 2021.  You asked the Plan to pay for the venous catheter replacement and fluoroscopic guidance. You say that the surgeon provided services which were appropriate based on being medically necessary. You say that you are requesting retro-authorization and for the claim to be reprocessed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.   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. Therefore, we decided that the Plan does not have to pay for the venous catheter replacement and fluoroscopic guidance provided by an out-of-network provider on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 2, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 remains not supported.  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 G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."  We find that code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.  You asked the Plan to pre-approve a group 3 power wheelchair. You say that this specific power wheelchair is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not satisfy the coverage criteria for the requested power wheelchair.    The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:  1. A neurological condition;  2. Myopathy; or  3. Congenital skeletal deformity.  The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on March 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that authorization should have been obtained by the facility or the referring physician. You also say that the provider saw this enrollee in good faith and should be paid for their services provided. The Plan denied your request. The Plan says both the referring and rendering providers are non-participating with the Plan. The Plan also says that no services for either provider were authorized by the Plan.  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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on March 29, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve provisional splinting - extracoronal (D4321) for the upper arch.  You asked the Plan to pre-approve provisional splinting. You say that your previous chemotherapy treatment has destroyed your teeth. You also say that you feel this should be part of your medical covered benefits. The Plan denied your request. The Plan says provisional splinting is not a covered service.  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 provisional splinting - extracoronal (D4321) for the upper arch.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nerve conduction studies coded 95908, the needle electromyography coded 95861, and the electroencephalogram (EEG) coded 95955 provided on May 26, 2021.  You asked the Plan to pay for the nerve conduction studies, the needle electromyography, and the electroencephalogram (EEG). 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 supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 95908 is a column II code to column I code 95861. 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.  We also find that CPT codes 95908 and 95861 are not supported in the medical record. Specifically, the technical report did not include documentation of needle electromyography, 2 extremities with or without related paraspinal areas; therefore, code 95861 cannot be verified. The technical report did not include documentation of an electroencephalogram (EEG) during nonintracranial surgery (cartoid surgery); therefore, code 95955 cannot be verified.  Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies, the needle electromyography, and the electroencephalogram (EEG) have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded 95908, the needle electromyography coded 95861, and the electroencephalogram (EEG) coded 95955 provided on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve an acute inpatient hospital admission and services.  You asked the Plan to pre-approve acute inpatient hospital care. You say that an inpatient admission is medically necessary for this enrollee. The Plan denied your request. The Plan says that the criteria for an inpatient hospital admission are not met; the enrollee's care can be provided in an outpatient observation setting.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the documentation shows that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve an acute inpatient hospital admission and services.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acupuncture services (97810, 97814).  You asked the Plan to pre-approve acupuncture services. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says acupuncture is only covered by Medicare for chronic lower back pain.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the medical documentation we have received from your provider does not document a history of chronic lower back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture services (97810, 97814).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve robotic surgery.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.  We looked at the file and Medicare rules. The requested robotic surgery is described by code S2900. This code has a status indicator of I and is not valid for Medicare purposes. These services are not covered. Therefore, we decided that the Plan does not have to pre-approve robotic surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954), pontic (D6245), retainer crowns (D6740), and inhalation of nitrous oxide/analgesia (D9230) provided on August 23, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the prefabricated post and core, pontic, retainer crowns, and inhalation of nitrous oxide/analgesia. You say that you would like to appeal for a $1,000 reimbursement for this claim. You also say that nowhere in the membership booklet is the Plan's denial of payment backed up. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that charges incurred by Medicare opt out provider will not be reimbursed by the 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 covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954), pontic (D6245), retainer crowns (D6740), and inhalation of nitrous oxide/analgesia (D9230) provided on August 23, 2021 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the inpatient surgery services provided on July 22, 2021.  You asked the Plan to waive the deductible for the inpatient surgery services. You say that you were having bypass surgery and would not know if the doctor was in-network. The Plan denied your request. The Plan says the deductible applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to inpatient hospital care.   The item or service you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient surgery services were received on July 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the inpatient surgery services provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 28 surgical placements of an implant body: endosteal implants (D6010 x28).  You asked the Plan to pre-approve the endosteal implants. You say that you have five bottom teeth which are rotten and need to come out. You also say that you can barely eat and your dentures are uncomfortable. The Plan denied your request. The Plan says the supporting documentation does not indicate inability for you to retain a denture.  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 maximum allowance for implants is four [4] implants on the maxillary arch and two [2] implants on the mandibular arch. The record shows that you are requesting 14 implants for the maxillary arch, and 14 implants for the mandibular arch, which exceeds the allowance for implants per arch. Therefore, we decided that the Plan does not have to pre-approve 28 surgical placements of an implant body: endosteal implants (D6010 x28).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).  You asked the Plan to pre-approve the PWC. You say that you believe that the enrollee meets the criteria for coverage of a PWC. The Plan denied your request. The Plan says the enrollee's mobility needs are met with his current equipment in the home. The PWC is needed mostly for activities outside the home.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PWC. Our reviewer says that the documentation does not support that the criteria for the requested PWC are met. Our physician reviewer found the enrollee is a male with a prior history of stroke with left sided weakness and unstable gait. Based on the medical records provided there is no documentation that this patient has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Records indicate the power mobility device is being requested to shop outside the home. Provided records report the patient uses a walker and manual wheelchair in the home presently.   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 PWC have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture with resin base (D5211).  You asked the Plan to pre-approve a partial denture. You say that you need this service. The Plan denied your request. The Plan says partial upper denture with resin based 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 partial upper denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture with resin base (D5211).
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 these services are medically necessary. The Plan denied your request. The Plan says that your 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. You were admitted with a spinal cord infarct. The record indicates that you have not been able to be weaned from the ventilator and have persistent hypoxic failure due to neuromuscular weakness. The medical record does not indicate that you require acute care services that you are not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.    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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing billed for services provided on March 10, 2021.  You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed services cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and the rules. We find that CPT codes 8157, 80519, 80162, 80173, 80177, and 80162 are not supported in the medical record. Specifically, the billed tests are inconsistent with the type of specimen obtained by the enrollee. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing billed for services provided on March 10, 2021.