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

 We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage implant surgery) (D6011).  You asked the Plan to pre-approve surgical access to an implant body. You say that this service is medically necessary. 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 pre-approve surgical access to an implant body (second stage implant surgery) (D6011).
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided to the enrollee on June 14, 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 claims were not initially billed under a UB-04 to establish the required HHA reports on the 0023-revenue code line the date of the first covered visit provided during the initial episode; therefore, the Medicare rule for payment of this claim has not been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed due to an issue with the revenue code billed. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on October 26, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extraction (D7140) provided on May 21, 2021.  You asked the Plan to pay for the extraction. You say that you received a bill for $600.43. You say that you needed these dental services before you could have surgery. You also say that you need help with this bill. The Plan denied your request. The Plan says there is a 50% coinsurance for extractions received in network. The Plan also says that the claim was processed correctly.  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 extraction is listed as covered, there is a 50% coinsurance for extractions received in network. $76.77 x 50% = $38.39. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) provided on May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on December 11, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99239 is not supported.

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 99239 is hospital discharge day management; more than 30 minutes. 

We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of hospital discharge services spent on the enrollee. 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 pay for the hospital discharge services rendered on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture treatment to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve acupuncture treatment to be provided by the requested out-of-network provider. You say that due to the long one-way travel time and distance of 100 miles, you would like to be treated by the requested provider. The Plan denied your request. The Plan says you have in-network alternatives, which are both closer to your home than the requested provider. The Plan has redirected you to a closer in-network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatment to be provided by the requested out-of-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prism eyeglasses.

You asked the Plan to pre-approve prism eyeglasses. You say that you have double vision which impacts your daily life, and you are not able to drive at night because of double vision. The Plan denied your request. The Plan says based on a review of the information received, it was determined that we have not received documentation from your provider indicating that the requested prism glasses are needed to treat a problem resulting from cataract removal.

The Plan must follow Medicare rules. Medicare rules say that one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL is covered. Medicare rules also say Covered diagnoses are limited to pseudophakia (condition in which the natural lens has been replaced with an artificial intraocular lens [IOL]), aphakia (condition in which the natural lens has been removed but there is no IOL), and congenital aphakia. Lenses provided for other diagnoses will be denied as non-covered.

We looked at the file and the Medicare rules. Medicare says one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL is covered. Medicare says covered diagnoses are limited to pseudophakia (condition in which the natural lens has been replaced with an artificial intraocular lens [IOL]), aphakia (condition in which the natural lens has been removed but there is no IOL), and congenital aphakia. Lenses provided for other diagnoses will be denied as noncovered. Therefore, we decided that the Plan does not have to pre-approve prism eyeglasses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 6.

You asked the Plan to pre-approve the dental service. You say that the enrollee is very reluctant to have tooth # 6 extracted. You also say that a root canal is necessary. The Plan denied your request. The Plan says root canal 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 requested root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 6.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on July 20, 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 must 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 out of network lab services provided to the enrollee on July 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from October 21, 2020, to October 30, 2020.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you are experiencing financial hardship due to the pandemic and cannot afford this cost-share. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 for each of the first six days of an inpatient stay. There is a $0 copay for additional days.  You have been asked to pay a $1,500 copayment for an inpatient hospital stay which exceeded six days ($250 x 6 days = $1,500). 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 the inpatient hospital admission and services provided from October 21, 2020, to October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an immediate maxillary partial denture (D5223) provided by a participating provider.  You asked the Plan to pay for an immediate maxillary partial denture. You say that you would like this appeal reprocessed and approved. The Plan denied your request. The Plan says D5223 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 an immediate maxillary partial denture (D5223) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergency routine transportation trips.

You asked the Plan to provide coverage for additional non-emergency routine transportation trips. You say that you need additional transportation trips for your medical appointment The Plan denied your request. The Plan says you have exhausted the benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 6 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used the maximum number of transportation trips. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergency routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia, initial 15 minutes, (D9222) and general anesthesia, each additional 15 minutes (D9223).

You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says general sedation 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 requested general anesthesia services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve general anesthesia, initial 15 minutes, (D9222) and general anesthesia, each additional 15 minutes (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services rendered on April 22, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99053 is not separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the medical services rendered on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on March 4, 2021.  You asked the Plan to pay for this claim. 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 must 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 out of network lab services provided to the enrollee on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 (J7320).

You asked the Plan to pre-approve Genvisc 850. The Plan denied your request. The Plan says this request does not meet the the Plan's Part B step therapy criteria for the requested viscosupplement device.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Genvisc 850. Our reviewer says that Genvisc 850 (J7320) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has not tried and failed the required drug, Monovisc. Our physician reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc 850 have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 (J7320).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation more than 50 miles.

You asked the Plan to pre-approve non-emergency transportation. You say that you have upcoming follow-up appointments, and you must be seen at a specific location. You say that you are requesting an exception for rides that are over 50 miles. The Plan denied your request. The Plan says that your plan has a limit of 50 miles per one-way trip.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 30 one-way rides per year within 50 miles. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the requested provider is over 50 miles away. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation more than 50 miles.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on June 2, 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 must 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 physician services provided to the enrollee on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).

You asked the Plan to pre-approve the dental items. You say that you previously received ill fitting dentures from an in network dentist. You say that a new dentist advised that they could make you new dentures that fit. You say that you were advised that you would have to pay up front for the dentures and be reimbursed. You also say that you do not understand what difference it makes if the dentist is in or out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dentures are not among those covered under this benefit when performed by an out of network dentist. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth #22.

You asked the Plan to pre-approve endodontic therapy. 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 pre-approve endodontic therapy for tooth #22.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diagnostic computed tomography (CT) of the thorax with contrast material.  You asked the Plan to pre-approve the CT of the thorax with contrast material. You say that the requested CT scan is important for continuous monitoring and to observe changes so that the enrollee can be treated accordingly. The Plan denied your request. The Plan says surveillance or screening imaging is not supported because the enrollee's lung nodule(s) have gotten larger in size and/or increased in number.  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 of the thorax with contrast material. Our reviewer says that the criteria for coverage of the requested type of CT scan have not been met at this time. Our physician reviewer found the enrollee had the most recent scan on September 20, 2021. A repeat chest CT scan would not be medically necessary until 3 months after the previous scan. Our physician reviewer also found that the type of CT scan being requested includes intravenous contrast, which is not necessary to image the lung nodules.  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 of the thorax with contrast material have not been met. Therefore, we decided that the Plan does not have to pre-approve diagnostic computed tomography (CT) of the thorax with contrast material.