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

 We decided that the Plan does not have to pay for the root canal (D3310) provided on August 16, 2021.  You asked the Plan to pay for the dental service. You say that this service was needed as a result from dental issues that arose after your radiation therapy. You say that an extraction was not possible due to the bone damage that resulted from the radiation therapy. You also say that this service was medically necessary. The Plan denied your request. The Plan says the service you received is dental in nature. The Plan also says that routine dental services are not covered.  Medicare generally does not cover dental services. The Plan follows the same rule.    The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the root canal (D3310) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on August 31, 2021, by an out-of-network (OON) provider  You asked the Plan to pay for an office visit. You say that you cannot afford to pay $6,567. You also say that you were not aware that your state is not a referral state. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have 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 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 an office visit (99213) provided on August 31, 2021, by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628), for the enrollee.  You asked the Plan to pre-approve the intracept procedure. You say that the intracept procedure is medically necessary and the most effective treatment for this enrollee. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental for lower back pain (LBP). More research is needed.  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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code 64628), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for preparation and provision of antigens for allergen immunotherapy provided on July 21, 2020, and July 22, 2020, billed with 25 units on each date of code 95165.  You asked the Plan to pay for the total 50 units of code 95165. You say that this should be paid as billed. The Plan denied your request. The Plan says the documentation does not support the number of units billed of this code.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the total 50 units of code 95165 Our reviewer says that the documentation does not support the number of units billed on these dates.   Our physician reviewer found the submitted documentation consists of an "Immunotherapy Mixing Worksheet" with a mix date of 7/21/20, as well as an "Encounter Summary" 7/21/20 and 7/22/20. The documentation does not contain enough information to calculate the units as there is no dose listed on the mixing sheet. Therefore, this procedure cannot be verified.  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 total 50 units of code 95165 have not been met. Therefore, we decided that the Plan does not have to pay for preparation and provision of antigens for allergen immunotherapy provided on July 21, 2020, and July 22, 2020, billed with 25 units on each date of code 95165.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from August 13, 2021, to September 13, 2021.  You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the charges because you thought that you would own the equipment and feel the rental items are unnecessary. 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 20% coinsurance for DME and related supplies.   You received DME and related supplies from August 13, 2021, to September 13, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.   Date of Service Service Allowed Amount Amount You Owe 8/13/2021 DME and Related Supplies $48.74 $9.75 8/17/2021 DME and Related Supplies $43.98 $8.80 9/13/2021 DME and Related Supplies $48.74 $9.75  The total amount you owe is: $28.30.  You have been asked to pay the total coinsurance amount of $28.30 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided from August 13, 2021, to September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (01935) provided on October 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for anesthesia services. You say that you want this claim to process under the member's in-network level of benefits, due to the fact that the facility and/or the surgeon participate with the plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have 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 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 anesthesia services (01935) provided on October 6, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET)/computed tomography (CT) scan for the enrollee.  You asked the Plan to pre-approve the scan. You say that the consensus was to repeat this scan. The Plan denied your request. The Plan says the scan in September should have been sufficient.  The Plan must follow Medicare rules. Medicare rules say that PET 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee underwent stereotactic body radiation therapy (SBRT) treatment in 2016, but the record indicates that the enrollee is not receiving treatment currently. The enrollee had a PET scan in September that demonstrate a potentially suspicious lesion. The requested PET scan is not being requested to guide subsequent management of anti-tumor treatment strategy after completion of initial anti-cancer therapy. The elements of the coverage criteria are not satisfied.  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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET)/computed tomography (CT) scan for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the forearm cast application and special supplies provided on July 6, 2021, billed with codes 29075-LT and 99070, respectively.  You asked the Plan to pay for the services as billed. You say that this should have been billed with modifier -50. You also state that 99070 should be paid by the Plan. The Plan denied your request. The Plan says these codes are not appropriate for the services rendered.  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, code 29075 was billed with modifier -LT. The record shows that the casts were placed bilaterally as do the reported diagnosis codes. Though a corrected claim was included with an appeal, this was not submitted to the Plan's claims department. The initial denial based on the modifier/diagnosis code mismatch is supported. In addition, code 99070 has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this is always bundled with other services, and not made separately. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the forearm cast application and special supplies provided on July 6, 2021, billed with codes 29075-LT and 99070, respectively.   We note that it appears a corrected claim was submitted during the review of this case. We cannot act on or process claim corrections. Corrected claim information may be submitted directly to the Plan for further review. We are only permitted to make a decision based on the claim information reviewed by the Plan for payment. Please submit any corrections or additional claim information directly to the Plan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 15, 2021.  You asked the Plan to pay for the tooth extraction. You say that you thought tooth extractions would be covered under all dental plans. The Plan denied your request. The Plan says this service is not covered under your 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 the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Accu-chek guide test strips for the enrollee.  You asked the Plan to pre-approve Accu-chek guide test strips. You say that the enrollee has been using Accu-chek since 2014. The Plan denied your request. The Plan says that the member does not meet criteria for coverage of non-preferred diabetic supply.  The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome.  We looked at the file and Medicare rules. The file does not include any documentation why the enrollee requires this specific brand of test strips. Without this, medical necessity cannot be established. Therefore, we decided that the Plan does not have to pre-approve Accu-chek guide test strips for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat sacroiliac joint (SIJ) injection for the enrollee.  You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the provided documentation does not provide appropriate indicators of improvement to be able to repeat the request.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no coverage for a subsequent sacroiliac (SI) joint injection when previous diagnostic or therapeutic SI injection of anesthetic and/or steroid to block joint for immediate, and potentially long-lasting, pain relief have not effectively relieved pain. In this case, there is no evidence of pain relief from visit to visit or after listed procedures. It is noted that even after previous injection and spinal cord stimulator procedures, pain has persisted and affected the enrollee's gait and activities of daily living (ADLs). It is also not clear how long previous injections lasted.  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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat sacroiliac joint (SIJ) injection for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for an office visit provided on July 14, 2021.  You asked the Plan to waive the copayment for an office visit. You say that your primary care physician is in-network, and you were billed for an out-of-network office visit. The Plan denied your request. The Plan says that the claim was processed and paid as an out-of-network office visit.  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 enrollees must pay a $0 copayment for each In-Network Medicare-covered primary care doctor visits.   The Plan says you must pay a $40 copayment for an out-of-network office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for an in-network office visit. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on July 14, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc injections (J7325).  You asked the Plan to pre-approve Synvisc injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  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 Synvisc injections. Our reviewer says that Synvisc is not medically necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the shoulder. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition.  The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections (J7325).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from July 30, 2021, through September 30, 2021.  You asked the Plan to pay for SNF services. You say that your husband was being discharged from the hospital and you could bring him home because you could not take care of him due to his mental health issues going on at the time. The Plan denied your request. The Plan says custodial care is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for SNF services provided from July 30, 2021, through September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from September 27, 2021, to October 29, 2021.  You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you should only owe a $30 copayment for the services and are being charged an additional $32. 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 20% coinsurance for Medicare Part B prescription drugs.   You received Medicare Part B drugs on September 27, 2021. The total allowed amount is $13.69 and 20% of that is $2.74.   You received Medicare Part B drugs on October 29, 2021. The total allowed amount is $13.64 and 20% of that is $2.73.  The total amount you owe is: $5.47.  You have been asked to pay the total coinsurance amount of $5.47 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from September 27, 2021, to October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital inpatient services, subsequent hospital care services provided from December 8, 2020, through December 9, 2020.  You asked the Plan to pay for hospital inpatient services, subsequent hospital care services. The Plan denied your request. The Plan say members must receive their care from a network provider. Member may receive care from out-of-network providers under limited circumstances, and only if the services are covered benefits and are medically necessary.  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 hospital inpatient services, subsequent hospital care services provided from December 8, 2020, through December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a hysteroscopy performed from September 30, 2021, to October 1, 2021.  You asked the Plan to waive the copayment for the hysteroscopy. You say that your doctor's assistance informed you that there would not be any copayment for the procedure. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $295 copayment for surgical procedures performed in an outpatient hospital.   You have been asked to pay a $295 copayment for the hysteroscopy. The hysteroscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 hysteroscopy performed from September 30, 2021, to October 1, 2021.