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

We decided that the Plan has to pay for the surgery services (13100, 28112, 15004, and 15275) provided on April 2, 2021.
You asked the Plan to pay for the surgery services. You say that the claims were submitted correctly and should be paid. The Plan denied your request. The Plan says that the operative note indicates the procedures were performed on April 3, 2021.
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 the surgery services reported are supported in the medical record. Specifically, the header in the operative report indicates that this is an unsigned transcription, which is where the date of service of April 3, 2021, is listed. Meanwhile, in the signature area, it indicates a date and time that it was dictated and transcribed of April 3, 2021. We can reasonably conclude that the date in the header is not referring to the date of service of the procedure, because the procedure would not be done concurrently with the dictation/transcription. Based on this information, we decided that Medicare rules for coverage of the surgery services have been met. Therefore, we decided that the Plan has to pay for the surgery services (13100, 28112, 15004, and 15275) provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and re-cement or re-bond crown (D2920) provided on June 21, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and re-cement or re-bond crown. You say that your crown came off and you needed it to be re-cemented. You also say that you would like these services to be covered because you feel these services would prevent future problems. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 problem focused limited oral evaluation (D0140) and re-cement or re-bond crown (D2920) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the RFA services. You say that the attached clinical documentation supports the need for the requested RFA services. The Plan denied your request. The Plan says the records do not show that the enrollee has had two medically reasonable and necessary diagnostic injection with each one providing at least 80% relief required for an initial RFA. The Plan says that the records show the enrollee received prior facet joint injections in the lumbar spine with 70% pain relief.
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint injection procedures and facet joint denervation are covered when 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 the RFA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic low back pain due to spondylosis, which has failed conservative treatment. A series of two diagnostic facet injections was performed, however, the enrollee did not achieve greater than 80% improvement with either diagnostic injection. The records show that prior facet joint injections in the lumbar spine provided 70% pain relief. The records do not show that the enrollee has had two medically reasonable and necessary diagnostic injection with each one providing at least 80% relief required for an initial RFA. 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care provided on July 9, 2021.
You asked the Plan to pay for subsequent observation care. You say that The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent observation care provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on April 23, 2021.
You asked the Plan to pay for the scaling and planing. You say that you would like this service to be covered by the Plan. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that you were not enrolled in the optional dental rider.
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 periodontal scaling and root planing (D4341) provided on April 23, 2021.
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 IRF care is necessary for the enrollee to get back to her prior level of functioning. The Plan denied your request. The Plan says under Medicare, your request is not medically necessary.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax.
You asked the Plan to pre-approve a CT scan. You say that a spot was found on the last CT you had done and want another scan to make sure a biopsy does not need to be done. The Plan denied your request. The Plan says that the requested services are not medically necessary.
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. Our reviewer says that the documentation does support that the requested CT scan is medically reasonable and necessary. Our physician reviewer found you had a CT scan of the chest on August 2021 that showed bilateral nodules with early cavitation. The records indicate that you were recommended to have a CT scan repeated after a course of antibiotics to assess for resolutions versus persistence that would suggest inflammatory or neoplastic characteristics. The record indicates that you had a CT abdomen August 16, 2021. The provided records indicate the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Therefore, you meet criteria for the requested CT scan. 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 have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee in this case. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. FDA approval is for the treatment of high-risk early stage triple-negative breast cancer, in combination with chemotherapy as neoadjuvant therapy, then continued as a single agent as adjuvant therapy following surgery. This patient has already received chemotherapy and surgery and radiation is planned. The use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on May 26, 2021.
You asked the Plan to waive the copayment for lab services. You say that you got a notice that you would not owe anything for lab services. 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 $0 copayment for lab services provided at a primary care providers office, a specialists office, a standalone lab facility or an urgent care facility and a $25 copayment for lab services provided at an outpatient hospital facility. The record shows that you received lab services at an outpatient hospital facility on May 26, 2021. Therefore, you are responsible to pay the $25 copayment.
You have been asked to pay a $25 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 lab services provided on May 26, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on May 16, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on May 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) provided
on July 14, 2021, and July 15, 2021.
You asked the Plan to pay for the scalings and planings. You say that prior to the services being rendered the
insurance team was contacted and provided details advising that the treatment was covered at 100%. The Plan
denied your request. The Plan says this service is not a covered benefit under the enrollee's dental plan. The
Plan also says that the provider submitted a predetermination and contacted the Plan and was advised that this
service was 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, 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
periodontal scalings and root planings (D4341) provided on July 14, 2021, and July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal paracentesis procedures you
had at an outpatient hospital from January 15, 2021, to June 29, 2021.
You asked the Plan to waive the copayment for the abdominal paracentesis procedures. You say that you
believe the copayment is too high for this service. The Plan denied your request. The Plan says you were
charged these copayments 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 $275
copayment per visit for outpatient surgery and services at an outpatient hospital facility.
You have been asked to pay a $275 copayment per visit for the abdominal paracentesis procedures. The
abdominal paracentesis procedures fall within the outpatient surgery and services at an outpatient hospital
facility 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 abdominal paracentesis
procedures you had at an outpatient hospital from January 15, 2021, to June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on May 18, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the
records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services
provided by a physical therapy assistant on May 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that rehabilitation therapy for the member cannot be achieved at a lower level of care. The Plan denied your request. The Plan says that the services the enrollee requires can safely be received at a different setting.
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 daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet 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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the post removal (D2955) provided on June 24, 2021.
You asked the Plan to pay for the post removal. You say that this service was done as part of the procedure to retreat an existing root canal that had become infected multiple times. You also say that during the retreatment, it was necessary to remove the post in order to reach the infected areas. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the post removal (D2955) provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a resin-based composite posterior (D2391) provided by an out-of-network provider on June 23, 2021.
You asked the Plan to pay for a resin-based composite posterior. You say that you do not know why an anterior filing would be covered but a posterior filling is not. The Plan denied your request. The Plan says the dental services provided are not covered benefits.
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 a resin-based composite posterior (D2391) provided by an out-of-network provider on June 23, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genomic testing services (81201, 81295,81298,81403,81404,81405,81406,81407,81408 and 81479) provided on April 8, 2021.
You asked the Plan to pay for the genomic testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the billed codes are considered mutually exclusive to the codes that have been approved and paid.
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. Specifically, the services on this claim were billed with modifier XS to indicate these were services that are distinct because they were performed on a separate organ/structure. The Plan has failed to forward a legible claim to determine if the use of the XS modifier is inappropriate. It is the burden of the Health Plan to substantiate their denial with evidence. This denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the genomic testing services (81201, 81295,81298,81403,81404,81405,81406,81407,81408 and 81479) provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional radiofrequency ablation session.
You asked the Plan to pre-approve the services. You say that this procedure has offered the enrollee almost a year's worth of pain relief. The Plan denied your request. The Plan says there have been two sessions within the past 12 months.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. There have been two sessions of RFA within the past 12 months: RFA of the right lumbar spine on December 28, 2020, and RFA of the left lumbar spine on December 30, 2021. 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 pre-approve an additional radiofrequency ablation session.