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

We decided that the Plan does not have to pre-approve the hearing aid batteries.
You asked the Plan to pre-approve the hearing aid batteries. You say that you are unable to purchase batteries on a long-term status due to your financial circumstances. You say that the duration of the battery isn't going to last long, and you are asking for a consideration of the batteries. The Plan denied your request. The Plan says the requested batteries do not meet the definition of durable medical equipment.
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 hearing aid batteries.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair or transfer bench.

You asked the Plan to pre-approve a shower chair or transfer bench. You say that this transfer bench is required for safety. The Plan denied your request. The Plan says this equipment is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that shower equipment is not covered because it is not primarily medical in nature. While this item may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair or transfer bench.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to a skilled nursing facility.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says a transfer is being requested to an out-of-network facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to a skilled nursing facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99291) provided on June 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE was exceeded.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 the services (99291) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for scaling in presence of generalized moderate or severe gingival inflammation, full mouth, after oral evaluation (D4346) provided January 27, 2021.

You asked the Plan to pay for the dental services. You say that you were told there would not be additional charges for the service and everything was covered by the insurance. You were very surprised that you received a bill for $184.60. Please help you to not pay this amount. The Plan denied your request. The Plan says that the services is not covered when patient has had prior treatment for periodontitis.

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. 

The provider who rendered the services is a contracted provider. The Plan contract does not indicate that this service would not be covered. Under Medicare rules, this means the dental services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for scaling in presence of generalized moderate or severe gingival inflammation, full mouth, after oral evaluation (D4346) provided January 27, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional extractions and complete upper denture.
You asked the Plan to pre-approve the additional extractions and complete upper denture. You say that the 12 extractions and upper denture are medically necessary. You say that the dentist told you the procedures were needed, and this should be covered by the Plan. The Plan denied your request. The Plan says only one extraction per calendar year is covered and dentures are not a covered 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, you also have a maximum benefit of one extraction per year. The Plan already pre-approved one extraction, which exhausted your benefit. The complete upper denture remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pre-approve the additional extractions and complete upper denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the coinsurance for outpatient surgery you had on July 9, 2021.

You asked the Plan to waive or reduce the outpatient surgery. You say that you were not aware that the cost for this service would be this high and this amount is a financial hardship for you. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for outpatient surgery.

You have been asked to pay 20% coinsurance for the outpatient surgery. 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 or reduce the coinsurance for outpatient surgery you had on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft, first site in quadrant (D4263 x 2), bone replacement graft, each additional site (D4264 x 4), and guided tissue regeneration (D4267 x 6).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says bone replacement grafts are not listed as covered services. The Plan says that guided tissue regeneration are not listed as covered services either.
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 pre-approve a
bone replacement graft, first site in quadrant (D4263 x 2), bone replacement graft, each additional site (D4264 x 4), and guided tissue regeneration (D4267 x 6).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on March 30, 2021.
You asked the Plan to pay for the dental services. You say that you were not aware that the dentist's network status would change when you changed plans. You say that you were never made aware of the network changes. You also say that you saw this provider last year and there was no issue. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services and the hospital outpatient clinic visit
(G0463) rendered by the out-of-network (OON) provider on March 29, 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 a 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 laboratory services and the hospital outpatient clinic visit (G0463) rendered
by the out-of-network (OON) provider on March 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had at an outpatient hospital facility on March 25, 2021.
You asked the Plan to waive the copayment for the ECG. You say that this test was done as part of a surgery you had on April 1, 2021, so there should not be a separate copayment. 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 $50 copayment for diagnostic tests at an outpatient hospital facility.
You have been asked to pay a $50 copayment for the ECG. The ECG falls within the diagnostic tests at an outpatient hospital facility benefit category. Diagnostic tests that you have in preparation for surgery are not considered part of the surgery itself and are separately payable. 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 electrocardiogram (ECG) you had at an outpatient hospital facility on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 12, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that the provider is your new primary care provider and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $30 copayment for specialist visits. The record shows that you had an office visit with a provider not listed as your primary care physician on June 12, 2021. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the doctor visits 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 a specialist visit provided on June 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from October 21, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued inpatient mental health care is medically necessary for this enrollee. The Plan denied your request. The Plan says as of October 21, 2021, psychiatric care at the inpatient level were no longer medically necessary. The enrollee is compliant with treatment and able to tend to their basic daily needs. Ongoing care can be provided in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the Plan's denial of continued inpatient psychiatric care from October 21, 2021, onward is appropriate in this case. Our physician reviewer found that the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on October 15, 2021 with Schizophrenia, Chronic Condition with Acute Exacerbation. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. This patient did not show any abnormal behaviors or any symptoms which would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 21, 2021 forward as this patient was not shown to be a danger to herself or others.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services from October 21, 2021, onward.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on
June 23, 2021.
You asked the Plan to pay for the computed tomography (CT). 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 payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
for the computed tomography (CT) has a bundled relationship with code 70496 and cannot be paid as billed.
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT)
coded 70450 provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve application of desensitizing resin for cervical and/or root surface, per tooth (D9911 x 4).
You asked the Plan to pre-approve the dental services. You say that you feel that you need work done on your teeth. You also say that you feel that the plan should cover it. The Plan denied your request. The Plan says application of desensitizing resin for cervical and/or root surface, per tooth 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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve application of desensitizing resin for cervical and/or root surface, per tooth (D9911 x 4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehab needs require an inpatient rehab stay and close physical supervision. The Plan denied your request. The Plan says the intensive rehabilitation program is not medically necessary, and the member appears unstable for transfer.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

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 find that CPT code 99211 is not supported in the medical record. Specifically, the documentation shows that the services were billed with place of service (POS) code 12 (home). The services in question were not provided during a home visit, but in the office setting.

Therefore, it is inappropriate to billed POS 12 for these services. 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 the services provided on February 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the STIMQ Peripheral Nerve Stimulator (PNS) System.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that this is unproven and not medically necessary for the treatment of
this your condition.
The Plan must follow Medicare rules. Medicare rules say that no payment may be made for the implantation of
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the
conditions listed unless LCD criteria are met.
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 requested services are not considered medically reasonable and necessary in this case. Current peer
reviewed literature does not support the use of this device for chronic low back pain. Our physician reviewer
found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the STIMQ Peripheral Nerve Stimulator (PNS) System.
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) or pay more for the endodontic therapy (D3320), and crown (D2740) provided from May 19, 2021, to June 24, 2021.

You asked the Plan to pay for the prefabricated post and core, and to pay more for the endodontic therapy, and crown. You say that you received a pre-approval for these services and had no reason to doubt you could afford these procedures. You also say that you would like the Plan to reimburse you the remaining $688.30 that should have been covered according to all of the agents you spoke with prior to the procedures being approved. The Plan denied your request. The Plan says the prefabricated post and core is not a covered service. The Plan also says that the endodontic therapy and crown services were paid 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, post and core in addition to crown
(D2954) is not among those covered under this benefit. The contract also clearly states that you are responsible
for a 70% coinsurance for both endodontic therapy (D3320) and crown (D2740) that are provided in-network.
Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to
crown (D2954) or pay more for the endodontic therapy (D3320), and crown (D2740) provided from May 19,
2021, to June 24, 2021.