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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), provided on May 6, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says you have exceeded the Plan's maximum frequency for this 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 items or services are not among those covered under this benefit. Specifically, you have exceeded the Plan's maximum frequency for
this service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria is not met.

The Plan must follow Medicare rules. The Plan follows Medicare rules. The rules say that therapeutic CGMs
may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced in the
Medicare rules section.

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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record does not indicate that the enrollee injects insulin three or more times a day and that the
regimen requires frequent adjustments. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2) provided on May 27, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that these x-rays are considered preventive and provide a more comprehensive view of the lower teeth and bone structure. The Plan denied your request. The Plan says these services are not covered benefits 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 first intraoral periapical x-ray (D0220) and two additional intraoral periapical x-rays (D0230 x2) provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a
pneumatic appliance (E0673) provided on March 22, 2021.

You asked the Plan to pay for an intermittent limb compression device and a pneumatic appliance. You say that
the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says
pneumatic compression devices are not covered by Medicare for deep venous thrombosis.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression
device (E0675) and a pneumatic appliance (E0673) provided on March 22, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyewear provided on March 23, 2021.

You asked the Plan to pay an additional amount for the eyewear. You say that you are supposed to receive a free pair of eyeglasses after cataract surgery. The Plan denied your request. The Plan says the correct coinsurance was applied to the claim.

The Plan contract says the Plan covers post cataract eyewear with a 30% coinsurance for one pair of Medicare-covered eyewear.

We looked at the file and the Plan's rules. The file shows that the Plan processed the claim correctly based on the Plan's Medicare-covered eyewear benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided on March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 2, 2021, through April 13, 2021 and the office visit provided on March 5, 2021.
You asked the Plan to pay for the additional supplies and materials and office visit. You say that that the records clearly show what kind of precautions were taken by the provider prior to treating the patient and the code 99072 should be reprocessed for prompt payment. You say that you are also requesting reimbursement for the office visit for the services provided to the patient by a licensed provider. The Plan denied your request. The Plan says payment for code 99072 is bundled and not eligible for separate reimbursement. The Plan also says that code 99202 is not covered when provided by a chiropractor.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We find that CPT code 99072 is not supported in the medical record. CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. The records show that the service at issue billed by the chiropractor is an office visit not manual manipulation of the spine. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials and office visit have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from March 2, 2021, through April 13, 2021 and the office visit provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on January 12, 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 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 definitive drug testing rendered on January 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician attendance and supervision of hyperbaric
oxygen therapy (HBOT), per session (CPT code 99183 X 20) and hyperbaric oxygen under pressure, full body
chamber, per 30 minute interval (CPT code G0277 X 80), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the records show that the enrollee has burn wounds of their foot, caused by
a hair dryer. The Plan states the records sent by the provider indicates that the enrollee does not have a
compromised skin graft or other qualifying wound, and the request is for HBOT for treatment of the enrollee's
burn wounds.
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 services. Our physician reviewer
found the record indicates that the enrollee has a less than 1% total body surface area thermal burn on the foot
without skin graft. Thermal skin burns are excluded from coverage. The elements of the coverage criteria are
not satisfied. The requested service cannot be recommended.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve physician attendance and supervision of hyperbaric oxygen therapy (HBOT), per session
(CPT code 99183 X 20) and hyperbaric oxygen under pressure, full body chamber, per 30 minute interval (CPT
code G0277 X 80), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit provided on April 27, 2021.
You asked the Plan to reimburse you for the office visit (99213). You say that you paid out of pocket and would like to be reimbursed for the entire charge. The Plan denied your request. The Plan says the claim was paid, the Medicare allowable, to the provider minus the coinsurance.
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 30% coinsurance for Out-of-Network office visits.
You have been asked to pay 30% coinsurance for the office visit (99213). The office visit (99213) falls within the Out-of-Network office visit benefit category. The Plan confirmed with the provider you are only responsible for $26.83. 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 reimburse you for the office visit provided on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the brain (70551) provided
at an outpatient hospital on April 21, 2201.

You asked the Plan to waive the copayment for an MRI scan of the brain. You say that you were unaware of a
charge. The Plan denied your request. The Plan says the correct copayment was 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 $150
copayment for advanced imaging services provided at an outpatient hospital.

You have been asked to pay a $150 copayment for an MRI scan of the brain. An MRI scan of the brain 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 an MRI scan of the brain (70551) provided at an outpatient hospital on April 21, 2201.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on February 18, 2021 by a non-participating provider.

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 rendered by a non-participating provider without prior authorization.

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 the chiropractic services provided on February 18, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the HLA typing laboratory services provided on March 31, 2021.
You asked the Plan to pay for the HLA typing laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The HLA typing laboratory services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the HLA typing laboratory services provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the oral evaluation and complete series x-ray. We decided that the Plan does not have to pay for the filling.
You asked the Plan to pay for the oral evaluation and complete series x-ray. You say that you were under a different plan when you received the services in this case. You say that you were told that you had exceeded the amount. You also say that the services should be covered. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 calendar years.
The Plan says that complete series x-ray is covered once every 5 years. The Plan says that 2 fillings are covered per calendar year. The Plan also says that the frequency limits for these services have 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.
We decided that the Plan has to pay for the comprehensive oral evaluation and complete series x-ray.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Specifically, the frequency limits have not been exceeded for these services. The record shows that the comprehensive oral evaluation and complete series x-ray were paid while you were enrolled in a different plan. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation and complete series x-ray.
We also decided that the Plan does not have to pay for the filling for tooth # 9.
Though the Plan offers a dental benefit in excess of Medicare coverage and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a filling that you received on March 15, 2021, and a filling that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the filling.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay for radical prostatectomy surgery for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says this surgery can be approved as outpatient.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case.
Our physician reviewer found the expected length of stay for robotic radical prostatectomy is typically less than two or more midnights, unless the enrollee has complications or major comorbidities. The medical records do not reveal any significant comorbidities, and as such, the enrollee would not require an inpatient stay for this surgery. 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 pay for an inpatient stay for radical prostatectomy surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the fitting and insertion of an intravaginal support device provided on October 14, 2020, and October 28, 2020.
You asked the Plan to waive the copayments for the fitting and insertion of an intravaginal support device. You say that you do not know why the charges are not being covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.
You received the fitting and insertion of an intravaginal support device at an outpatient hospital facility on October 14, 2020. The fitting and insertion of an intravaginal support device is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $162.13, which is less than the $260 copayment. You received the fitting and insertion of an intravaginal support device at an outpatient hospital facility on October 28, 2020. The fitting and insertion of an intravaginal support device is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $162.13, which is less than the $260 copayment. The total amount you owe is: $324.26. You have been asked to pay the total copayment amount of $324.26 for the fitting and insertion of an intravaginal support device. The fitting and insertion of an intravaginal support device falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the fitting and insertion of an intravaginal support device provided on October 14, 2020, and October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that your health is deteriorating, and you require an IRF admission The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided on December 18, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not supported by the documentation.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The documentation does not include medical records that contain sufficient documentation of the enrollee's medical condition to substantiate the necessity for the type and quantity of items ordered or for the frequency of use. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor supplies provided on December 18, 2020