Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the podiatry services (11730, 11732) provided on May 19, 2021.
You asked the Plan to waive the deductible for the podiatry visit. You say that you only expected to pay your specialist visit copayment, and you have never had to pay this cost toward a deductible before. The Plan denied your request. The Plan says this claim was processed correctly and in accordance with your contract.
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 podiatry services. You pay a $35 copayment after the deductible is met for each Medicare-covered podiatry visit. The item or service you asked the Plan to waive the deductible for falls within the benefit category podiatry services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to podiatry services. This cost sharing is a contractual obligation that had not been met at the time the podiatry visit was received on May 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the podiatry services (11730, 11732) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the single-tooth x-ray you had on
September 17, 2020.
You asked the Plan to waive the coinsurance for the single-tooth x-ray. You say that this is a covered service,
so you should not be getting charged. The Plan denied your request. The Plan says [Enter plan denial rationale,
e.g. "...rules for SNF care have not been met."]
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 50%
coinsurance for Class 2 Basic Dental services, including single-tooth x-rays.
You have been asked to pay 50% coinsurance for the single-tooth x-ray. 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 coinsurance for the single-tooth x-ray you had on September 17, 2020
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to hold you harmless for the ankle sleeve provided on April 26, 2021.
You asked the Plan to hold you harmless for the ankle sleeve. You say that you would like reconsideration because you are being billed for equipment that was thrown away by the nurse. The Plan denied your request. The Plan says that non-prescription items are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. We looked at your request, the file and Medicare rules. Based on this information we decided that coverage criteria have been met. Specifically, you state that you are being billed for equipment that you tried on that was thrown away. No clinical information has been submitted to determine if you have received the items at issue. Therefore, we decided that the Plan has to hold you harmless for the ankle sleeve provided on April 26, 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 waive the copayment for the urgent care visit you had on June 26, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were only at the urgent care center for five minutes and you feel as though they should have done more for you. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for urgently needed care. You have been asked to pay a $65 copayment for the urgent care visit. This copayment applies regardless of how low the services last. 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 urgent care visit you had on June 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
care in a SNF. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not
been met. The Plan says that the enrollee's needs can be met at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and
inhaled medications, had stable vital signs, under kyphoplasty, and was treated for pain. The enrollee received
physical therapy and occupational therapy. The enrollee was at a contact guard assist supervision level with
functional mobility, including gait to short distances. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy
service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nivolumab and taxotere.
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 medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has metastatic squamous cell carcinoma of the soft palate. The combination of nivolumab and taxotere is not approved by the Food and Drug Administration (FDA) for squamous cell head and neck cancer. The use is not supported by the medical literature or major drug compendia. The combination is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve nivolumab and taxotere
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on May 19, 2021.
You asked the Plan to pay for the dental services. You say that you needed a tooth extracted. You also say that you opted to have deep sedation for what you felt could be a painful procedure. The Plan denied your request. The Plan says deep sedation services are not listed as covered dental 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 deep sedation services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral/facial photographic images (D0350) and diagnostic casts (D0470) provided on March 3, 2021.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for these services and believed they were covered. The Plan denied your request. The Plan says these services are 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 oral/facial photographic images (D0350) and diagnostic casts (D0470) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the scaling and root planing for the upper left quadrant. We decided that the Plan does not have to pay for the scaling and root planing for the upper right quadrant.
You asked the Plan to pay for the dental services. You say that you did not have a deep cleaning done. You
also say that you would like the claim to be reviewed. The Plan denied your request. The Plan says scaling and
root planing is covered once every three years, per quadrant. The Plan also says that the frequency limit 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.
We decided that the Plan has to pay for the scaling and root planing for the upper left quadrant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the scaling and root planing for the upper left quadrant have been met.
Specifically, there is no record that the Plan has paid for this service in this last 3 years. Therefore, we decided
that the Plan has to pay for the scaling and root planing for the upper left quadrant.
We also decided that the Plan does not have to pay for the scaling and root planing for the upper right
quadrant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the scaling and root planing for the upper right quadrant have not been met.
Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for scaling and root
planing for the upper right quadrant that you received on February 17, 2020, less than 3 years ago. Therefore,
we decided that the Plan does not have to pay for the scaling and root planing for the upper right quadrant.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission is 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 pre-approve these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was discharged from the
hospital on October 7, 2021 after an admission for syncope. She is able to walk but is essentially bedbound by
choice. The physical therapy and occupational therapy notes show that she is at her baseline level of function.
She has no skilled nursing needs or skilled therapy needs. She does not require skilled nursing or skilled
therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an
inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (CPT code 99053) provided to the enrollee on March 22, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services is not covered as billed by the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99053, has a status indicator of 'B' on the Centers for Medicare and Medicaid Services (CMS) Physician Relative Value File, and is always bundled into payment for other services not specified and no separate payment is made per Medicare. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (CPT code 99053) provided to the enrollee on March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for common procedural terminology (CPT) codes 74174-26 and
74175-26-59 billed for date of service March 29, 2021.
You asked the Plan to pay for CPT codes 74174-26 and 74175-26-59. You say that the enrollee had multiple
exams on the date of service in dispute. You say that the reports provided support the level of service being
billed. The Plan denied your request. The Plan says the records provided do not support the services that were
billed and that are in dispute.
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 information must be
submitted to corroborate the documentation in the enrollee's medical records and to confirm that Medicare
coverage criteria have been met.
We asked our coder 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 CPT codes 74174-26 and 74175-26-59. Our reviewer says
that the criteria for coverage of the CPT codes in dispute have not been met. Our reviewer found the
documentation submitted does not document pelvic area which consists of bladder, prostate, and other male
reproductive organs, which is included with CPT 74174. The radiology report also does not clearly document
findings of with and without contrast to confirm procedure was performed. The report should clearly document
without contrast sequences and with contrast sequences in the report, to confirm procedures were performed.
Postprocessing is not documented in the radiology report and cannot be confirmed as performed. The
documentation does not clearly document the level of service represented by CPT code 74175. The report does
not clearly document the procedure was performed with and without contrast. Documentation should clearly
document with and without contrast sequencing to confirm procedure has been performed. Also, the
documentation to does not include evidence of postprocessing and therefore, cannot be confirmed as
performed. In addition, modifier 59 would be inappropriate to report in this case, since CPT guidelines for CPT
code 74174 state that it should not be reported in conjunction with CPT codes 72191, 73706, 74125, 75635,
76376, and/or 76377.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT codes 74174-26 and 74175-26-59 have not been met. Therefore, we
decided that the Plan does not have to pay for common procedural terminology (CPT) codes 74174-26 and
74175-26-59 billed for date of service March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed provided on April 12, 2021.
You asked the Plan to pay for the total electric hospital bed. You say that the records support the need for the equipment. The Plan denied your request. The Plan says the criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital bed provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extractions you received on April 14, 2021.
You asked the Plan to pay for the dental extractions. You say that this dentist was in-network so these services
should be paid. The Plan denied your request. The Plan says these dental services were denied because you
have already exceeded your maximum $2000 dental benefit for this year. The Plan did not deny these claims
based on the provider's network status.
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, you have exhausted this benefit for
2021. Therefore, we decided that the Plan does not have to pay for the dental extractions you received on April
14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses, fitting, and refraction testing provided on February 16, 2021.
You asked the Plan to pay for the routine vision services. You say that this should be paid. The Plan denied your request. The Plan says these are routine vision services and must be provided by an  network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an  network provider. We looked at the file and the Plan's rules. The routine vision care was rendered by a provider not in-network with. Based on this information, we decided that the Plan's rules for coverage of the routine vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses, fitting, and refraction testing provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue regeneration (D4265), intravenous (IV) moderate sedation, initial 15 minutes (D9239), and intravenous moderate sedation, each additional 15 minutes, (D9243 x 3) provided on May 18, 2021.
You asked the Plan to pay for biologic materials for tissue regeneration and the IV sedation. You say that the bridge had to be removed because it was abscessed. You say that the tooth was a stand alone and could not support any kind of pressure. You say that you could not have had the surgery without the sedation.
The Plan denied your request. The Plan says the biologic materials to aid in soft and osseous tissue regeneration is not listed as a covered service. The Plan also says that the sedation services are not covered when they are performed in conjunction with other services that 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the intravenous sedation have not been met. Specifically, the file shows that the anesthesia was performed in conjunction with a simple extraction. A simple extraction is not a complex surgical dental service and therefore is not covered. Additionally, biologic materials for tissue regeneration and is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue regeneration (D4265), intravenous (IV) moderate sedation, initial 15 minutes (D9239), and intravenous moderate sedation, each additional 15 minutes, (D9243 x 3) provided on May 18, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen you had on April 22, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you don't believe this copayment is fair because the Plan only pays a small portion of this test. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient diagnostic services (including CT scans). You have been asked to pay a $300 copayment for the CT scan. The CT scan falls within the outpatient diagnostic services 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 the computed tomography (CT) scan of the abdomen you had on April 22, 2021.