Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a CT scan of the sinuses.  You asked the Plan to pre-approve a CT scan of the sinuses. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested service have not been met.  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 a CT scan of the sinuses. Our reviewer says that the requested service is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has had CT of the chest on July 27, 2021, and has had a nasal endoscopy on September 21, 2021. In addition, the enrollee has tried Flonase for 8 weeks and Omeprazole for 8 weeks without relief. Conservative management has been trialed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the sinuses have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the sinuses.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81406, 81405, 81407, 81408) provided May 17, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented cardiovascular disease.  We looked at the file and Medicare rules. The service at issue is cardiovascular risk assessment testing. This service is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81406, 81405, 81407, 81408) provided May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness (E2313) and electronics (E2311), extra payment for base wedge (K0108), and seat elevator (E2300).  You asked the Plan to pre-approve the advanced features for the power mobility device. You say that the features should be covered. The Plan denied your request. The Plan says they will overturn the request for a group 3 power wheelchair, but not the additional advanced features.  The Plan follows Medicare rules. Medicare rules say that power seat elevation feature (E2300) is  non-covered because they it is not primarily medical in nature. Since the enrollee is able to the control of the power options with their own switches, there is no need to control the power option through the joystick. The electrical connection between the wheelchair controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered. Although there are approved power options on this wheelchair, there is not a medical need to control these power options through the joystick. The base wedge is not covered. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness (E2313) and electronics (E2311), extra payment for base wedge (K0108), and seat elevator (E2300).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88112, 88305, 85060) provided on February 27, 2020, and March 1, 2020.  You asked the Plan to pay for laboratory services. You say that this was filed timely. The Plan denied your request. The Plan says this was filed more than a year after the dates of service.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for laboratory services was not filed until June 21, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for laboratory services (88112, 88305, 85060) provided on February 27, 2020, and March 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the wheelchair lift for a car (E1399).  You asked the Plan to pre-approve wheelchair lift. You say that you need the wheelchair lift to go places. The Plan denied your request. The Plan says this is not medical in nature.  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 the wheelchair lift for a car (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

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

 We decided that the Plan does not have to pay more toward the comprehensive oral evaluation and intraoral x-ray provided on May 25, 2021 and the limited oral evaluation provided on June 7, 2021.  You asked the Plan to pay more toward the comprehensive oral evaluation, intraoral x-ray and limited oral evaluation. You say that you went in for x-rays and exam and want to know how this could not be covered by dental insurance. The Plan denied your request. The Plan says the claim processed correctly.  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 Plan is only obligated to pay 50% of the allowed amount for the comprehensive oral evaluation. You are responsible for any amount greater than the payment made by the Plan to the out-of-network provider. You are also responsible for the full cost of the intraoral x-ray and limited oral evaluation as they are not covered benefits. Therefore, we decided that the Plan does not have to pay more toward the comprehensive oral evaluation and intraoral x-ray provided on May 25, 2021 and the limited oral evaluation provided on June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from May 4, 2021, through May 22, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the SNF services were not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term care).  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from May 4, 2021, through May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), preventive procedure (D1999), and consultation (D9310) provided on July 12, 2021.  You asked the Plan to pay for the cone beam CT capture and interpretation, pulp vitality tests, preventive procedure, and consultation. You say that you bought supplemental dental insurance to cover at least part of these procedures, used the list the Plan sent you, and two days before the procedure this provider advised they would cover none of the expenses. You also say that six of the seven providers the Plan offered you would not accept your insurance. The Plan denied your request. The Plan says these services 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, 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 cone beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), preventive procedure (D1999), and consultation (D9310) provided on July 12, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the services provided on February 8, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the service was paid to another provider.  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. In this case, the provider is only appealing 13 units of codes 88341 and 88305. The MUE for code 88341 is 13. As such, the Plan's denial for exceeding the MUE is not substantiated. There is also no evidence that the Plan paid another provider for code 88305. Therefore, we decided that the Plan has to pay for the services provided on February 8, 2021.   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 pay for an outpatient clinic visit (G0463) provided on March 3, 2021.  You asked the Plan to pay for the outpatient clinic visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-authorized or emergent.  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 services at issue in this appeal. The Plan did not pre-approve the service 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 an outpatient clinic visit (G0463) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on July 20, 2021.  You asked the Plan to pay for the dental services. You say that you have always gotten your teeth cleaning 2 times per year. You also say that on every Patient Plan Summary you have been given, it is advised you have dental cleanings consistently every 6 months. The Plan denied your request. The Plan says 1 periodic oral exam is covered per calendar year. The Plan says that 1 prophylaxis is covered per calendar year. The Plan also says that the frequency limits have 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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a periodic oral evaluation and prophylaxis that you received on January 8, 2021. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on July 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0428, A0425) provided on June 18, 2021.  You asked the Plan to waive the copayment for non-emergency ambulance services. You say that you should not have to pay for the services at issue. The Plan denied your request. The Plan says the copayment was 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 $250 copayment for ambulance services.   You have been asked to pay a $222.32 copayment for non-emergency ambulance services. The services at issue fall within the ambulance services benefit category. Since the Allowed Amount for this service is less than the required copayment of $250, you have been asked to pay only $222.32. 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 non-emergency ambulance services (A0428, A0425) provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330) and a resin-based composite (D2335) provided on August 9, 2021.  You asked the Plan to pay an additional amount for a comprehensive oral evaluation, a panoramic radiographic image, and a resin-based composite. You say that your last 3 visits to your previous dentist have been unsatisfactory. Your last filling started to come loose, and you decided to change your dental provider and the new provider reworked the last filling. You are requesting reconsideration of payment on this claim. The Plan denied your request. The Plan says you exceeded the maximum limit for coverage.  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.  We looked at the file and Medicare rules. The records show you exceeded the maximum limit for coverage as you previously had this procedure done on June 10, 2021. The records also show that you have received the $1,000 allowed benefit for the Plan year. The EOC confirms you pay 100% of charges beyond the $1,000 dental allowance. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a panoramic radiographic image and a resin-based composite have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for a comprehensive oral evaluation (D0150), a panoramic radiographic image (D0330) and a resin-based composite (D2335) provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chemotherapy administration (96401) provided on July 14, 2021.  You asked the Plan to pay for chemotherapy administration. You say that you are not using this code for chemotherapy administration. The Plan denied your request. The Plan says there is a more appropriate code for Prolia administration.  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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.  We find that CPT code 96401 is not supported in the medical record. Specifically, this code was used to report the administration of Prolia, which is not considered a chemotherapy agent. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96401) provided on July 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health services rendered on April 28, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial The Plan denied your request. The Plan says there is no documentation of consultation with the attending or primary care physician.  The Plan must follow Medicare rules. The rules say that a clinical psychologist must have a referral and consult from the beneficiary's primary care physician.    We looked at the file and Medicare rules. There is no documentation of a consult with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomographic angiography, of the chest with contrast material(s), including non-contrast images, if performed, and image postprocessing (71275) rendered by the out-of-network (OON) provider on June 26, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the computed tomographic angiography, of the chest with contrast material(s), including non-contrast images, if performed, and image postprocessing (71275) rendered by the out-of-network (OON) provider on June 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on June 16, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.   We looked at the file and Medicare rules. The file shows that the physician order is unsigned and thus not valid. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2020.  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 are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chemotherapy administration services rendered on April 5, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 96401 is 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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.  We find that CPT code 96401 is not supported in the medical record. Specifically, the documentation supports that there is a more appropriate code for the rendered services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration services rendered on April 5, 2021.