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

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that you had surgery and cannot sit up on your own. The
Plan denied your request. The Plan says that no daily skilled nursing needs are noted.

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 care. Our reviewer says that the
service is medically reasonable and necessary. Our physician reviewer found the enrollee does qualify for SNF
coverage. The enrollee has documented skilled nursing needs, in the form of regular wound care for multiple
wounds. The enrollee does not have documented skilled therapy needs, as the enrollee is functioning at/near his
baseline. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration
of the enrollee's condition.

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 care 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) care.

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 pay for the problem focused limited oral evaluation (D0140)
provided on May 28, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was a
continuation of an earlier claim from your dentist who referred you to an endodontist because they did not have
the equipment to make an evaluation. You also say that you believe this should be covered. The Plan denied
your request. The Plan says this service exceeds the frequency limitation in your benefit 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, problem focused limited oral
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem
focused limited oral evaluation (D0140) on May 14, 2021, and your problem focused limited oral evaluation
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation (D0140) provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and scaling and 
root planing, 1 to 3 teeth per quadrant, (D4342) for all 4 quadrants provided from May 18, 2021, to May 24, 
2021. 
 
You asked the Plan to pay for the dental services. You say that basic cleaning and inspection of your teeth is 
routine. You say that you have $1,000 for dental help. You say that you do not understand why the claims are 
not being paid. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan 
says 1 comprehensive oral evaluation or periodontal exam is covered every 3 years. The Plan says that the 
frequency limit has been exceeded. The Plan also says that scaling and root planing 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 and comprehensive oral evaluation is 
listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periodontal 
exam that you received on April 19, 2021. Additionally, scaling and root planing, 1 to 3 teeth per quadrant, are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150) and scaling and root planing, 1 to 3 teeth per quadrant, (D4342) for all 
4 quadrants provided from May 18, 2021, to May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May
27, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you believe the evaluation was
necessary for tooth #19. The Plan denied your request. The Plan says this procedure exceeds the frequency
limitations under your 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, emergency oral evaluation problem
focused exams are limited to once every 12 months. The record shows that you received a comprehensive oral
evaluation (D0150) on November 17, 2020, and your emergency oral evaluation problem focused exams
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation (D0150) provided on May 27, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the Arthroscopy, shoulder, surgical; with rotator cuff repair represented by code 29827 provided on February 3, 2021.
You asked the Plan to pay for code 29827. You say that the medical records support the billing of code 29827. The Plan denied your request. The Plan says that the medical records do not support the billing of code 29827.
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 29827 is Arthroscopy, shoulder, surgical; with rotator cuff repair. 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 code 29827. Our reviewer says that the medical records support the billing of code 29827. Our reviewer found detailed documentation is reasonably evident regarding supporting the substantial added work to the procedure code 29827 that includes those requiring marked increased effort. There is compelling rationale noted overall. Therefore, CPT code 29827-22 is supported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 29827 have been met. Therefore, we decided that the Plan has to pay for the Arthroscopy, shoulder, surgical; with rotator cuff repair represented by code 29827 provided on February 3, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for any physical agent applied to produce therapeutic changes to
biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy (97010)
provided on June 11, 2021.

You asked the Plan to pay for any physical agent applied to produce therapeutic changes to biologic tissue;
includes but not limited to thermal, acoustic, light, mechanical, or electric energy (97010). The Plan denied
your request. The Plan says CMS considers reimbursement for 97010 to be bundled into payment for other
services not specified. Consistent with CMS, Medicare considers these codes not eligible for reimbursement.

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 any
physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal,
acoustic, light, mechanical, or electric energy has a bundled relationship with code 97010 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 any physical agent applied to
produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical,
or electric energy (97010) provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth facility fee provided on April 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the telehealth facility fee. 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 records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the telehealth facility fee provided on April 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 24, 2021, by an
OON provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network
care.
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 physician services provided on February 24, 2021,
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on July 18, 2019, to July 21, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you already met your maximum out-of-pocket limit. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $200 copayment per day for days 1-8. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $200 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $600 ($200 x 3 days = $600). Your maximum out-of-pocket amount had not been met at the time of this services. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided by a participating provider on July 18, 2019, to July 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and five additional intraoral periapical x-rays (D0230 x5) provided on May 26, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that if you had known that these x-rays would not be covered you would not have had them done. The Plan denied your request. The Plan says these services are not covered benefits 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 first
intraoral periapical x-ray (D0220) and five additional intraoral periapical x-rays (D0230 x5) provided on May 26, 2021.
Your complaint about your disappointment with the Plan's coverage 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 12, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that your dental benefits state that these services are covered at $0 out-of-pocket for the member whether they are provided in-network or OON, but you are not being reimbursed. The Plan denied your request. The Plan says the total amount of $136 applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.
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 are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 12, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on May 24, 2021, by an
OON provider.
You asked the Plan to pay for the anesthesia services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
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 anesthesia services provided on May 24, 2021,
by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric recliner chair (E1399).
You asked the Plan to pre-approve an electric recliner chair. You say that the item is medically necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an electric recliner chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist office visit and the x-ray provided on March 3,
2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the specialist office visit and an x-ray. You say that the provider is in-network
and would like reconsideration of payment. 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.
Therefore, we decided that the Plan does not have to pay for the specialist office visit and the x-ray provided on
March 3, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Acyclovir (J8499) provided on June 13, 2021.

You asked the Plan to pay for the Acyclovir. You say that you would like that was administered to you without
prescription to be reconsidered for coverage under Part B of your plan coverage because it was rendered in the
emergency room. The Plan denied your request. The Plan says is a self-administered oral medication. The Plan
also says that Part D services are not covered under your medical plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Acyclovir (J8499) provided
on June 13, 2021.

Benefits for the Acyclovir may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the billed codes 95908, 95886, 95955, and 95937 provided April 26, 2021.
You asked the Plan to pay for the billed codes 95908, 95886, 95955, and 95937. You say that the medical records support the codes that were billed. The Plan denied your request. The Plan says the recorded services as billed are not supported in the medical records.
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 95908 is Nerve conduction studies; 3-4 studies
The CPT Code Manual definition of code 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The CPT Code Manual definition of code is 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 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 the billed codes 95908, 95886, 95955, and 95937. Our reviewer says that the medical documentation does not support the codes as billed. Our reviewer found that for CPT 95908 the technical report documents Pedicle stimulation, which would not be reported with this code. Nerve conduction studies include measurement of amplitude, latency and conduction velocity. Therefore, this procedure cannot be confirmed. For CPT 958856, to report a code, all procedures included in the code description should be performed. In this case, documentation does not support nerve conduction studies, therefore this procedure would not be covered. Next, for CPT 95955 the technical report supports "real-time" monitoring. There is a more appropriate code to report for this service. Documentation does not support an additional EEG was performed during procedure. Therefore, this service cannot be performed. Finally, for CPT 95937 the technical report does not include documentation of neuromuscular junction testing. This code should not be reported for train of four which is included with the primary neuromonitoring procedure. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the billed codes 95908, 95886, 95955, and 95937 have not been met. Therefore, we decided that the Plan does not have to pay for the billed codes 95908, 95886, 95955, and 95937 provided April 26, 2021.