Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on August 27, 2020.
You asked the Plan to pay for the services provided. You say that you are dependent on receiving enrollee information from the ordering provider. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim shows a place of service as an office. The records provided indicate the enrollee's specimen was obtained at a skilled nursing facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision services provided on April 6, 2021.
You asked the Plan to pay for the services provided. You say that the removal and pathology were medically necessary to properly diagnose and treat the lesions. The Plan denied your request. The Plan says there is insufficient information to corroborate the services.
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 11606 is excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm. We find that CPT code 11606 is not supported in the medical record. Specifically, the records indicate lesions were removed to rule out malignancy. The records do not indicate malignant lesions were removed. There is a more appropriate code available to describe the services provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the excision services provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant placements (D6010 x 3), unspecified removable
prosthodontic service (D5899 x 2), immediate lower denture (D5140), complete upper denture (D5110), guided
tissue regeneration in conjunction with periradicular surgery (D3432 x 3), bone graft in conjunction with
periradicular surgery, each additional site (D3429 x 2), bone graft in conjunction with periradicular surgery,
initial site, (D3428)
You asked the Plan to pay for the implants, dentures, guided tissue regeneration, and bone grafts. You say that
you were under the impression that a predetermination was sent to the Health Plan to show her full
responsibility. You also say that you would not have had this work done if you had known it would not be
covered. The Plan denied your request. The Plan says the implants, dentures, guided tissue regeneration, and
bone grafts are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the implants, dentures, guided tissue
regeneration, and bone grafts are not among those covered under this benefit. Therefore, we decided that the
Plan does not have to pay for the implant placements (D6010 x 3), unspecified removable prosthodontic service
(D5899 x 2), immediate lower denture (D5140), complete upper denture (D5110), guided tissue regeneration in
conjunction with periradicular surgery (D3432 x 3), bone graft in conjunction with periradicular surgery, each
additional site (D3429 x 2), bone graft in conjunction with periradicular surgery, initial site, (D3428)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the brachial plexus injection services provided on February 15, 2021.
You asked the Plan to pay for the services provided. You say that this service is not included with any other service. The Plan denied your request. The Plan says the use of the modifier is not supported.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. We looked at the file and the rules. CPT code was billed along with code 01630. We find that code 64415 may be eligible for payment when billed with an appropriate modifier. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the brachial plexus injection services provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and removal of residual tooth roots (cutting procedure) (D7250) provided July 8, 2021.
You asked the Plan to pay for the dental consultation, tooth extraction and removal of residual tooth roots. You say that you were referred to the dentist and would like the Plan to cover the services. The Plan denied your request. The Plan says these services aren't 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 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), and removal of residual tooth roots (cutting procedure) (D7250) provided July 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services provided from August 5, 2020, through
August 13, 2020.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that the claims were received past the timely filing deadline.
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 Plan has not provided us with the dates that the claims were received by the Plan causing an untimely filing denial. Therefore, we decided that the Plan has to pay for physician's services provided from August 5, 2020, through August 13, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 services provided by an out-of-network provider on July 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided to the enrollee from October 2, 2020, to October 3, 2020.

You asked the Plan to pay for genetic testing provided to the enrollee. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says that this was an administrative denial based on a coding error. The Plan is basing their decision on the Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624), the Medicare Local Coverage Article (A57936): Billing and Coding: MolDX: Plasma-Based Genomic Profiling [Solid Tumors], and the Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer (A55197).

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 Plans are expected to use Medicare regulations that have a MAC B jurisdiction designation for either the state the enrollee lives in or the state in which the provider is located. The regulations referenced by the Plan do not show MAC B jurisdiction for the state the enrollee lives in or in the state the provider is located in and therefore do not apply. This means, the Plan has not substantiated its denial as the appropriate Medicare regulations were not used to determined coverage or coding guidelines. Therefore, we decided that the Plan has to pay for genetic testing provided to the enrollee from October 2, 2020, to October 3, 2020.

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 intraoral x-ray provided on August 6, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that the images done show what a normal bitewing image would show plus additional structure of the teeth. You say that dental x-rays are covered under preventive care and the dentist should be reimbursed at the rate of a bitewing x-ray. The Plan denied your request. The Plan says the service is 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 intraoral x-ray provided on August 6, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on July 14, 2021.
You asked the Plan to pay for an abdominal ultrasound. You say that the enrollee had multiple exams. The Plan
denied your request. The Plan says this is not separately 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 76705
is a column II code to column I code 93976.
This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an
abdominal ultrasound (76705) provided on July 14, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 68-year-old male with traumatic brain injury, subarachnoid hemorrhage, seizures and hypoglycemia, currently in inpatient rehabilitation facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite, one surface, posterior (D2391)
provided on July 14, 2021.
You asked the Plan to pay for the resin-based composite, one surface, posterior (D2391). You say that the tooth
had a ragged edge that was catching your inner lip as you ate. You say that this was causing extreme pain and
you found nothing in your available coverage that would indicate the lack of coverage. The Plan denied your
request. The Plan says the service is 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 resinbased
composite, one surface, posterior (D2391) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services.
You asked the Plan to pre-approve the dental services. You say that these dental services are medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested services are
not among the dental services that are covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided June 2, 2021.
You asked the Plan to pay for subsequent nursing facility care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper and lower denture provided on May
12, 2021.
You asked the Plan to pay more for the complete upper and lower denture. You say that you were informed
new dentures had to be purchased at an increased cost of $655. You say that the money sent to the provider
minus $125 for the x-rays and consultation should be returned. The Plan denied your request. The Plan says
you pay 100% of charges beyond the $1,000 allowance.
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 enrollee also has a maximum
benefit of $1,000 for covered dental services every year. The Plan paid $875 toward the dentures to meet the
$1,000 maximum, which exhausted the dental benefit. Therefore, we decided that the Plan does not have to pay
more for the complete upper and lower denture provided on May 12, 2021.
Your complaint about the member only receiving anxiety and frustration 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
You asked the Plan to pre-approve RFA of the SI joint. You say that this procedure is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated in the peer-reviewed literature.
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 RFA of the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested SI joint RFA is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on May 21, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance was
called because you thought you were having a stroke. You say when the ambulance arrived, they found out you
are diabetic and they checked your sugar and it was low and they gave you some glucose, and you felt better.
The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit. If there
is no transport, there is no covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on May 21, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Arrhythmia & Cardiomyopathy Comprehensive Panel provided on January 8, 2020.
You asked the Plan to pay for the Arrhythmia & Cardiomyopathy Comprehensive Panel. You say that this is necessary testing to check for genetic disorders. The Plan denied your request.
The Plan says this panel of tests will not affect the diagnosis or treatment of this member and her current symptoms. Traditional evaluation and subsequent treatment of persons with this member's clinical presentation does not include genetic testing.
The Plan must follow Medicare rules. Medicare rules say that germline hereditary genetic testing is covered only when certain criteria are met. Medicare requires that providers submit sufficient information to support that Medicare criteria are met. No records from the ordering provider were submitted for review. As such, it cannot be determined whether the LCD criteria are met. Therefore, we decided that the Plan does not have to pay for the Arrhythmia & Cardiomyopathy Comprehensive Panel provided on January 8, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the review has determined that the record does show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care