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

We decided that the Plan does not have to pay for the periodic oral exam (D0120), cleaning (D1110), bitewing
x-rays (D0274) and intraoral x-ray (D0220) provided on June 24, 2021, and fillings/restorations (D2391,
D2150) provided on August 3, 2021.
You asked the Plan to pay for the dental services. You say that you were told when you enrolled that your
current dentist was in-network and would have chosen a different plan if you knew dental care with this
provider would not be covered. The Plan denied your request. The Plan says the provider in this case is not part
of the Plan's dental network, and therefore 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. The Plan does not cover
supplemental dental care that is received out-of-network.
Though the Plan offers a dental benefit in excess of Medicare coverage, the provider in this case is not part of
the Plan's network. Therefore, we decided that the Plan does not have to pay for the periodic oral exam
(D0120), cleaning (D1110), bitewing x-rays (D0274) and intraoral x-ray (D0220) provided on June 24, 2021,
and fillings/restorations (D2391, D2150) provided on August 3, 2021.
Your complaint about potential misinformation from the Plan at the time of enrollment is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from November 5, 2020, through November 12, 2020, billed with secondary diagnosis codes J96.21 and J96.22.
You asked the Plan to pay for the inpatient services as billed. You say that this stay was correctly billed and should be paid at the requested DRG. The Plan denied your request. The Plan says the acute and chronic respiratory failure diagnoses are not supported which reduces the DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis codes J96.21 and J96.22, defined as acute and chronic respiratory failure with hypoxia & Acute and chronic respiratory failure with hypercapnia, respectively. 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 the inpatient services as billed. Our reviewer says that the reported secondary diagnosis codes are not considered to be medically reasonable and necessary. Our physician reviewer found the enrollee presented to the hospital with the symptoms of exacerbation of known chronic obstructive pulmonary disease (COPD). The enrollee was receiving oxygen at the same level as baseline. The hospital correspondence referenced medical literature regarding arterial blood gas evidence in their correspondence, however arterial blood gas results were not located in the records available. The review has determined that the documentation did not support the reporting of diagnosis codes J96.21 and J9622 (Acute and chronic respiratory failure with hypoxia & Acute and chronic respiratory failure with hypercapnia) as secondary diagnoses for this inpatient stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from November 5, 2020, through November 12, 2020, billed with secondary diagnosis codes J96.21 and J96.22.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on November 10, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on November 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 19, 2021, by an OON
provider.
You asked the Plan to pay for the office visit. You say that you were unaware the provider was out-of-network.
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 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 July 19, 2021, by an
OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for AlloSure testing (81479) provided on May 10, 2021.
You asked the Plan to pay for AlloSure testing. You say that this is a covered service. The Plan denied your request. The Plan says this is experimental.
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 pay for AlloSure testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found AlloSure testing (81479) is considered experimental. There is insufficient scientific data to determine whether this testing improves health outcomes.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AlloSure testing have not been met. Therefore, we decided that the Plan does not have to pay for AlloSure testing (81479) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the administration of seven bevacizumab eye injections received by a specialist (67028) from March 10, 2021, through September 23, 2021.
You asked the Plan to waive the copayment for the administration of eye injections. You say that you have been getting eye injections every month starting in February 2020. You say you have only been charged one copayment per visit until March 2021 when you started being charged two copayments per visit. You say the provider told you there should only be one copayment for a diagnostic eye exam and the eye injections. The Plan denied your request. The Plan says you were not charged an additional $25 copayment for the specialist administration of the eye injections prior to March 2021 due to a claims processing error. The Plan says they have chosen not to reprocess the claims as a courtesy; however, the Plan says this does not negate the fact that services were provided, nor does it revoke any contractual responsibilities.
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 $25 copayment for each Medicare-covered service received from an in-network specialist. You have been asked to pay $175 in copayments for the administration of seven eye injections ($25  7 = $175). Administration of eye injections by a specialist fall within the Physician/Practitioner Services benefit category. You received the additional injection services during diagnostic eye exams. These services are subject to an additional copayment under the Plan benefits since more than one type of service was provided. 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 administration of seven bevacizumab eye injections received by a specialist (67028) from March 10, 2021, through September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the obturator prosthesis, interim (D5936) provided January 6, 2021.
You asked the Plan to pay for the obturator prosthesis. You say that this service was medically necessary. The Plan denied your request. The Plan says a corrected claim is needed in order to process the appeal.
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 obturator prosthesis, interim (D5936) provided January 6, 2021.
Please note that this denial is based on the code the provider has submitted. You may wish to contact the provider to see if they can bill using a medical code instead
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on June 11, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. 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 record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 11, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428-HR,
A0425-HR) provided from a hospital facility to the enrollee's residence on March 3, 2021.
You asked the Plan to pay for the ambulance transportation. You say that the enrollee was transported twice on
the date in question. The Plan denied your request. The Plan says ambulance transportation was already paid
for this enrollee on this date under a separate claim. Both claims have the same diagnosis, billing codes,
providers and dates of service. This claim is processed as a duplicate.
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 A0428-HR is ambulance service, basic life support, nonemergency
transport, from a hospital to the enrollee's residence.
We find that CPT code A0428 with modifier HR is not supported in the medical record. Specifically, the
documentation does not support that the enrollee was transferred from the Hospital to a Residence twice on the
date in question. The Plan has already paid one claim billed for this date with modifier HR. Based on this
information, we decided that Medicare rules for coverage of the ambulance transportation have not been met.
Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation
(A0428-HR, A0425-HR) provided from a hospital facility to the enrollee's residence on March 3, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on July 14, 2021.
You asked the Plan to pay for ConfirmMDx testing. You say that this is a covered service. The Plan denied
your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85
years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being
considered for a repeat biopsy due to persistent or elevated cancer-risk factors.
We looked at the file and Medicare rules. The submitted records do not show that the enrollee was being
considered for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of
ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for
ConfirmMDx testing (81551) provided on July 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Synvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not outline contraindications or reasons these medications were not considered or that the plan's additional required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Synvisc is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on May 24, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on May 24, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), complete series of x-rays (D0210), four 2D oral/facial photographic images (D0350), oral hygiene instructions (D1330), and panoramic x-ray (D0330) provided on May 17, 2021.
You asked the Plan to pay for the dental services. You say that you were not informed about what services were going to be provided by this dentist. The Plan denied your request. The Plan says the services in question are either not covered by your dental benefit or were provided in a frequency that exceeds what is covered by your dental benefit. The Plan has paid the allowed rate for the cleaning, but the remaining services are denied.
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 2D oral/facial photographic images and oral hygiene instructions are not among those covered under this benefit. In addition, the Plan can only cover one comprehensive or periodontal oral exam every three years and one panoramic x-ray or complete series of x-rays every five years. Documentation shows that you had a previous periodontal oral exam and complete series of x-rays in June of 2020, which were covered by the Plan at that time. Therefore, it has not been three years since your last comprehensive or periodontal oral exam, and it has not been five years since your last full mouth or panoramic x-ray. The benefit for these services was already exhausted on the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150), complete series of x-rays (D0210), four 2D oral/facial photographic images (D0350), oral hygiene instructions (D1330), and panoramic x-ray (D0330) provided on May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy and biopsy (45380).
You asked the Plan to pre-approve the colonoscopy. You say that a follow-up colonoscopy is medically necessary. The Plan denied your request. The Plan says the requested colonoscopy is not medically necessary, as the enrollee already had a prior follow-up colonoscopy in 2017 which showed diverticulitis but no polyps. The request for a repeat colonoscopy is not reasonable and necessary at this time.
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 colonoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records provided support that the enrollee has already had a follow-up colonoscopy for this issue in 2017. The requested colonoscopy is not medically necessary in this case.
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 colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy and biopsy (45380).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

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 pre-approve SNF services. Our reviewer says that that SNF services are medically reasonable and necessary. You have documented skilled nursing needs, in the form of daily lower extremity dressing changes. You do not have documented skilled therapy needs. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare criteria for SNF 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 SNF services have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve structural allograft.
You asked the Plan to pre-approve structural allograft. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 structural allograft. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found for anterior cervical spine surgery; structural allograft is approved for 2 level surgery. Bone Morphogenic Protein (BMP) is not FDA approved for use in the anterior cervical spine. Allow structural allograft to use only. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of structural allograft have been met. Therefore, we decided that the Plan has to pre-approve structural allograft.
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.