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

We decided that the Plan does not have to pay more for the simple extractions (D7140) and deep
sedation/general anesthesia (D9222 and D9223) provided on May 27, 2021.
You asked the Plan to pay more for the simple extractions and deep sedation/general anesthesia. You say that
you were told this treating provider was in-network, and that these services would be covered at 100%. The
Plan denied your request. The Plan says your Dental plan allows $2,000 per plan year and you have satisfied
that maximum amount.
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 Plan offers an annual maximum
benefit of $2,000 every year. The record shows that you met the annual maximum benefit on June 20, 2021 and
your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay
more for the simple extractions (D7140) and deep sedation/general anesthesia (D9222 and D9223) provided on
May 27, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a presbyopia correcting function of an intraocular lens
(V2788).
You asked the Plan to pre-approve a presbyopia correcting function. You say that you have the benefit for an
intraocular lens following cataract surgery and believes this service should be covered due to your diagnosis,
co-morbid conditions and previous medical history that includes trauma due to a fall that affected your vision
in the right eye. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a
conventional IOL.
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve a presbyopia correcting
function of an intraocular lens (V2788)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 29, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 Guardant360 testing is not supported in the medical record. Specifically, the place of service
on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the
Guardant360 testing provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on August 7, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you have Part D coverage and want to preserve your rights. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.
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 self-administered drugs provided on August 7, 2021.
Benefits for the self-administered drugs 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, thorax, diagnostic; without contrast material (CPT
code 71250), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary because the enrollee has
pain. The Plan denied your request. The Plan says they do not have enough information to know if this
procedure is 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 the CT scan. Our physician reviewer
found left shoulder pain and history of lipoma does not qualify for CT chest. A chest x ray and chest ultrasound
are more appropriate studies in this case. The CT will not add any value to the case at this point and will
amount to over utilization and will expose the enrollee to unnecessary radiation. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT, thorax,
diagnostic; without contrast material (CPT code 71250), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) on June 23, 2021.
You asked the Plan to pay for the dental service. You say that your wife had issues with the previous dental office. You say that you both found a new dental office. You say that as a new patient, you had to have a full work up. You also say that you feel this should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation every 3 plan years. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on February 11, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) provided on July 6, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you feel the copayment is too high. You say you do not remember paying this amount in previous years. 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 $250 copayment per visit for outpatient diagnostic and therapeutic services and supplies, such as MRIs.
The record shows you had two images done on July 6, 2021. You have been asked to pay a total of $237.28 ($158.32 copayment + $78.96 copayment = $237.28), which is less than the $250 copayment for the MRI. An MRI falls 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 magnetic resonance imaging (MRI) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921 x 2) provided on August 27, 2021.
You asked the Plan to pay for the dental services. You say that you were not made aware of any charges by your dentist. You say that you were not charged at all. You also say that all you thought you were getting at the time was a cleaning. The Plan denied your request. The Plan says gingival irrigation is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival irrigation (D4921 x 2) provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7210) provided on June 3, 2021.
You asked the Plan to reimburse you for the dental service. You say that your insurance will pay any dental services that are submitted. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a provider that has opted out of Medicare.
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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the extraction (D7210) provided on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aflibercept 1MG injection (CPT code J0178), for the
enrollee.
You asked the Plan to pre-approve the injection. You say that it is medically necessary for the enrollee. The
Plan denied your request. The Plan says the provider has indicated that this drug is being dispensed by a
pharmacy- a Part D covered event. The Plan states the enrollee's Part B benefit says that to cover the drug, it
must be furnished by the enrollee's physician, an infusion center, or the hospital outpatient department.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve aflibercept 1MG injection (CPT code J0178), for the enrollee. Benefits
for the injection 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. You appear unable/unwilling to fully participate in
skilled therapy. Skilled services are not currently shown to be required to establish a maintenance program or
to prevent deterioration of your 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 not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removable prosthodontic procedures (D5899 x2) and
immediate maxillary denture (D5130) provided on January 26, 2021.
You asked the Plan to pay for the removable prosthodontic procedures and immediate maxillary denture. You
say that you have been waiting to have teeth since January 26, 2021. The Plan denied your request. The Plan
says the removable prosthodontic procedure is not a covered benefit. The Plan also says that your benefits for
the immediate maxillary denture have been satisfied and the frequency limitation has been exceeded.
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, unspecified removable prosthodontic
procedure (D5899) is not among those covered under this benefit. The contract says that complete dentures are
limited to one upper complete and/or one lower complete denture every five years. The record shows that you
received reimbursement for an immediate maxillary denture provided on March 4, 2019 and your complete
maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
two removable prosthodontic procedures (D5899 x2) and immediate maxillary denture (D5130) provided on
January 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided the Plan does not have to pay for diagnostic services provided on February 14, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the medical records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes and provide records to substantiate the services
billed. In this case, the records provided do not support the services billed. Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic services
provided to the enrollee on February 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of penile prosthesis for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication that medicine in the enrollee's urethra (Intraurethral medications) would not help the enrollee.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The medical records do not indicate that the enrollee has failed non-surgical treatment with a vacuum erection device or penile injections. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of penile prosthesis for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the acute inpatient hospital care
provided from July 1, 2020, to July 9, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the principal diagnosis code
is supported. The Plan denied your request. The Plan says the billing of principal diagnosis code A41.9, Sepsis,
unspecified organism, is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as Sepsis,
unspecified organism. 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 inpatient care. Our
physician reviewer found while the enrollee presentation warranted consideration of sepsis, there was no
evidence of life-threatening organ dysfunction due to dysregulated host response to infection. The reviewer
found that There was no evidence of life-threatening organ dysfunction due to dysregulated host response to an
infection, persistent hemodynamic instability or cognitive impairment that would be consistent with multi-
system involvement due to specifically to sepsis. Therefore, the reviewer found that the records did not support
the billing of principal diagnosis code A41.9, Sepsis, unspecified organism.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
an additional amount for the acute inpatient hospital care provided from July 1, 2020, to July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture adjustment (D5411) provided on August 3, 2021.
You asked the Plan to pay for the complete mandibular denture adjustment. You say that you contacted the Plan with a list of codes and charges to verify which were covered under medical and dental. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that prior to this date of service when you contacted the Plan, you verified if several codes were covered, but code D5411 was not mentioned during this call.
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 complete mandibular denture adjustment (D5411) provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) and therapeutic parenteral drugs (D9612) provided on July 26, 2021.
You asked the Plan to pay for the consultation and therapeutic parenteral drugs. You say that you sent a pre-authorization to the Plan but did not get a response, and later found out that the pre-authorization should have been sent in by the provider. You also say that you never had a consultation, and you needed the drugs to take you out of being sedated. The Plan denied your request. The Plan says these services are not covered expenses 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 consultation (D9310) and therapeutic parenteral drugs (D9612) provided on July 26, 2021.