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

We decided that the Plan does not have to pay for arthrocentesis (22610 and 22614) and laminectomy (63046 and 63048) services rendered by an assistant-at-surgery on January 22, 2021.
You asked the Plan to pay for the services provided by an assistant-at-surgery. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include the name of the assistant surgeon.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We find that CPT codes 22610-AS, 63046-AS, 22614-AS and 63048-AS are not supported in the medical record. Specifically, the documentation submitted does not support that an assistant-at-surgery was present. The records do not include the assistant's name or indicate that an assistant was used. There is insufficient information to verify the services billed. Based on this information, we decided that Medicare rules for coverage of the services provided by an assistant-at-surgery have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis (22610 and 22614) and laminectomy (63046 and 63048) services rendered by an assistant-at-surgery on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says there is no need for the use of an expandable controller for the standard joystick.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on May 14, 2021. 
 
You asked the Plan to pay for the dental item. You say that the denture that was billed in 2020 did not fit. You 
say that you went back for an adjustment, but it still did not fit. You say that it was causing you pain. You also 
say that you would like the payment reversed and applied to this denture as you did not receive the previous 
one. The Plan denied your request. The Plan says 1 partial upper denture is covered every 5 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 partial upper denture is listed as 
covered, the frequency limit has been exceeded. The record shows that the Plan paid for a partial upper denture 
that you received on January 13, 2021. Additionally, the record shows that the provider advised that they would 
made the adjustments needed so the partial would fit. Therefore, we decided that the Plan does not have to pay 
for the partial upper denture (D5213) provided on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by an 
ambulatory facility on February 12, 2021, to March 26, 2021. 
 
You asked the Plan to waive the copayment for a cystoscopy. You say that you do not know why you are being 
billed twice. 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 $75 
copayment for outpatient surgery/ambulatory surgical center.  
 
You have been asked to pay a $75 copayment for a cystoscopy. The correct copayment has been applied to the 
services that were provided. A cystoscopy falls within the outpatient surgery/ambulatory surgical center 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 outpatient surgery provided by an 
ambulatory facility on February 12, 2021, to March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.
You asked the Plan to pre-approve acupuncture. You say that there is considerable research to indicate that acupuncture is an effective practice to minimize the effects of tics. The Plan denied your request. The Plan says you do not meet criteria for the requested services.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the documentation does not support that you are requesting acupuncture services for chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on May 10, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you were never helped. You say that the doctor was extremely rude. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Evidence was provided to show that an emergency room visit was provided; therefore, the correct copayment has been applied. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99441) provided on March 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is included in the primary procedure.
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 99441 is "Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion". We find that CPT code 99441 is not supported in the medical record. Specifically, the documentation shows that CPT code 99203 was billed and paid to the same provider on March 16, 2021, which is within 7 days of the service at issue. The provider has not submitted documentation showing that the telephone call was unrelated to the evaluation and management visit. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99441) provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and physician services provided on December 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit and physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 and physician services provided on December 17, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share charged for outpatient mental health care.
You asked the Plan to waive this cost share. You say that you should not be responsible for these co-payments and feel you are being penalized because you have poor internet. The Plan denied your request. The Plan says these copayments were charged based on the Plan contract and the claims submitted by your provider.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay $35 copayment for each outpatient mental health visit. 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 cost share charged for outpatient mental health care provided from December 10, 2020, to May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve the lift. You say that you have nerve damage in your feet. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig purchased by the enrollee on February 10, 2021.
You asked the Plan to pay for wigs of any type. You say that this wig was medically necessary. The Plan denied your request. The Plan says wigs are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Wigs do 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 pay for a wig purchased by the enrollee on February 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the topical application of fluoride, excluding varnish, (D1208) provided on May 4, 2021.
You asked the Plan to pay the in network rate for the fluoride application. You say that when you signed up with the plan you were advised that you could go to any dentist for your cleanings. You say that you were advised only specialists needed to be approved. You also say that had you known you needed to use an in network dentist, you would have looked for one that was in network. The Plan denied your request. The Plan says the topical application of fluoride, excluding varnish, 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, the topical application of fluoride, excluding varnish, is not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay the in network rate for the topical application of fluoride, excluding varnish, (D1208) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 18, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you were unaware that the facility did not
obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by
the member's primary care physician or facility.
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 skilled nursing services provided on February 18, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant, providing
care in the home, per hour (S9122) provided from March 15, 2020, to July 24, 2020.
You asked the Plan to pay for the home health services. You say that your claim has been denied for multiple
reasons. You say that your doctors prescribed you around the clock certified nursing assistant (CNA) along
with home physical, occupational and speech therapies. You say that you need this claim settled once and for
all. The Plan denied your request. The Plan says the provider in this case is not eligible to participate in
Medicare. The Plan also says that payment cannot be made to providers that are not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the home health aide or certified nurse
assistant, providing care in the home, per hour (S9122) provided from March 15, 2020, to July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on May 7, 2021.
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 enrollee did not have prior authorization for 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 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 medical services provided to the enrollee on May
7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown and custom abutment (D6066, D6057) provided March 10, 2021 to April 8, 2021.
You asked the Plan to pay for the crown and abutment. You say that the services were medically necessary. The Plan denied your request. The Plan says the dental services at issue are not covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown and custom abutment (D6066, D6057) provided March 10, 2021 to April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2), the bone replacement graft for ridge preservation (D7953), the extraction (D7140), the implant (D6010), and the non-intravenous conscious sedation (D9248) provided on February 16, 2021.
You asked the Plan to pay for the dental services. You say that you needed your tooth extracted before it broke off at the gum line. You also say that the services were medically necessary. The Plan denied your request. The Plan says the dental services you received 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 scaling and root planing, bone replacement graft, extraction, implant, and non-intravenous conscious sedation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2), the bone replacement graft for ridge preservation (D7953), the extraction (D7140), the implant (D6010), and the non-intravenous conscious sedation (D9248) provided on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of full mouth x-rays (D0210) provided on April 29, 2021.

You asked the Plan to pay for the full mouth x-rays. You say that you were told you were allowed to see a new dental provider and now feel like you were lied to because your services were not covered. The Plan denied your request. The Plan says only one panoramic or full mouth series of x-rays can be covered every three years. You previously had a complete series of full mouth x-rays provided in April 2019, which was paid for by the Plan. This is less than three years before the date in question, so this service will not be covered.

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. The Plan can cover one panoramic or complete series of x-rays every three years. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the x-rays are requested in a frequency that is not covered under this benefit. Documentation shows that the Plan paid for full mouth x-rays for you in
April 2019, which is less than three years before the date at issue in this case. Therefore, we decided that the Plan does not have to pay for the complete series of full mouth x-rays (D0210) provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided April 22, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you do not remember being provided with drugs during the procedure. The Plan denied your request. The Plan says the record shows the self-administered drugs were provided. These are not covered.
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 provided are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) provided April 22, 2021.