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

We decided that the Plan does not have to pre-approve bone grafts and jaw reconstruction.
You asked the Plan to pre-approve the dental services. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the requested dental services are not covered by Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the bone grafts and jaw reconstruction are not medically necessary. Our physician reviewer found any treatment to restore missing bone in the dental arch would be to restore the missing alveolar ridges for use as support for implants or dentures. The reviewer found that the dental portion of the Plan states as an exclusion "Reconstructive surgery of any type, including reconstructive surgery related to a dental disease, injury, or congenital anomaly." The reviewer found that the anticipated surgery would be to correct alveolar bone loss which is directly attributable to the loss of teeth from decay or other dental disease. Therefore, the reviewer found that the requested surgery is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, dental services including reconstruction surgery of any type including reconstructive surgery related to a dental disease, injury, or congenital anomaly are excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve bone grafts and jaw reconstruction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for DME and related supplies provided on March 17, 2021.
You asked the Plan to waive the deductible and coinsurance for DME and related supplies. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible. Your contract with the Plan also clearly says that after the $150 deductible has been met, enrollee's must pay 20% coinsurance for DME and related supplies.
The enrollee received DME and related supplies on March 17, 2021. The record shows that you had paid $0 toward the $150 deductible prior to receiving the services. Therefore, you are responsible to pay the $150 deductible. Now that $150 deductible has been met, you are also responsible to pay 20% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. $161.29 - $150 = $11.29 and 20% of that is $2.26. The total amount you owe is: $152.26. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible for DME and related supplies. This cost sharing is a contractual obligation that had not been met at the time DME and related supplies were received on March 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for DME and related supplies provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial lower denture (D5214).
You asked the Plan to pre-approve the dental service. You say that the service should be covered. The Plan denied your request. The Plan says you did not sign up for the optional supplemental dental coverage. The Plan also says that a lower partial denture is not listed as 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 partial lower denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips
for doctor's appointments for kidney specialist and other providers. The Plan denied your request. The Plan
says the requested services exceed your benefit limit. 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 30 one-way trips per year to plan-approved locations for network
physicians, medical facilities, and pharmacies.
We looked at your request, the records in the case file, and the rules. 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 pre-approve 8 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an office visit and an X-ray provided on February 5, 2021.
You asked the Plan to waive the copayments for an office visit and an X-ray. You say that you disagree with the charges because you received the services due to having had the coronavirus. 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 $25 copayment for primary care provider visits. Your contract with the Plan also clearly says that you must pay a $15 copayment for X-rays. You had an office visit on February 5, 2021. The coronavirus waiver for primary care provider visits expired on December 31, 2020. Therefore, you are responsible to pay the $25 copayment. You received an X-ray on February 5, 2021. The coronavirus waiver for X-rays expired on December 31, 2020. Therefore, you are responsible to pay the $15 copayment. The total amount you owe is: $40. You have been asked to pay the total copayment amount of $40 for an office visit and an X-ray. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. An X-ray 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 copayments for an office visit and an X-ray provided on February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) (L0650) provided on December 7, 2020.
You asked the Plan to pay for the LSO. You say that the item is medically necessary. The Plan denied your request. The Plan says the orthosis was prescribed without a face-to-face evaluation, physical examination or imaging demonstrating medical necessity.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a LSO have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) (L0650) provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), intraoral x-rays (D0220 and D0230) and re-cement or re-bond crown (D2920) provided on April 14, 2021.
You asked the Plan to pay more for the limited oral evaluation (D0140), intraoral x-rays (D0220 and D0230) and re-cement or re-bond crown (D2920). You say that you would not know the doctor was only in-network at a different location. You say that the claim should be treated as being provided by an in-network provider and the charges should be reduced. The Plan denied your request. The Plan says the claim processed correctly per your out-of-network 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 Plan is only obligated to pay the allowed amount for the limited oral evaluation and intraoral x-rays and 50% of the allowed amount for the re-cement or re-bond crown. You are responsible for the remaining amount above what the Plan pays for dental services received from an out-of-network dentist. Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), intraoral x-rays (D0220 and D0230) and re-cement or re-bond crown (D2920) provided on April 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the member has stabilized medically and
is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy
services on a daily basis. He is medically stable and can receive further rehab services at a lower level of
care. Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.
The member does not have any parental medication; complex wound care or nutrition given via a feeding
tube. He is medically stable without any acute exacerbations of chronic medical problems. His physical
function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for
inpatient skilled rehab services is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on April 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. 

We found no exception that would require the Plan to pay for these items/services. The record shows the drug testing was ordered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the drug testing provided on April 21, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that admission from a swing bed to a SNF is not a lateral move for the enrollee. The Plan denied your request. The Plan says that the clinical information provided does not indicate a need for continuing skilled nursing or rehabilitation for the enrollee. 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional unit of hyperbaric oxygen therapy services represented by code 99183 provided on March 29, 2021.

You asked the Plan to pay for code 99183. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.

We find that 2 units of CPT code 99183 are not supported in the medical record. The medical record only supports 1 unit of CPT code 99183. Based on this information, we decided that Medicare rules for coverage of code 99183 have not been met. Therefore, we decided that the Plan does not have to pay for the additional unit of hyperbaric oxygen therapy services represented by code 99183 provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.
You asked the Plan to pre-approve an office visit. You say that this care is necessary for your treatment. The
Plan denied your request. The Plan says they have in-network providers available to provide the same
treatment.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office visit to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot insert (L3000), provided on June 3, 2020.
You asked the Plan to pay for the foot insert. You say that the item should be covered. The Plan denied your request. The Plan says the provider confirmed they do not accept Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the record indicates that the provider at issue was not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's enrollment in Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the foot insert (L3000), provided on June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravascular ultrasonography (36012, 37252, 75820, 75822).
You asked the Plan to pre-approve intravascular ultrasonography. You say that this is necessary to evaluate and confirm the enrollee's condition. The Plan denied your request. The Plan says other options are more appropriate.
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 intravascular ultrasonography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has significant saphenous vein reflux and varicosities that have not been treated. The provided records do not support the medical necessity and reasonableness of the requested service for the enrollee's 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 intravascular ultrasonography have not been met. Therefore, we decided that the Plan does not have to pre-approve intravascular ultrasonography (36012, 37252, 75820, 75822).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on March 1, 2021.

You asked the Plan to pay for periodontal maintenance. You say that this should have been paid 50% per the out-of-network benefit. You say that the claim should be reviewed for reprocessing. The Plan denied your request. The Plan says the claim 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, the Plan only pays 50% of the cost after your $100 deductible is met. The records show the $100 deductible was not met prior to this claim. Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided on March 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture (36415), basic metabolic panel (80048), complete blood count (85027), urine culture (87086), susceptibility studies (87186), and infectious agent detections by nucleic acid (U0003 and U0005) provided on February 8, 2021.
You asked the Plan to pay for the routine venipuncture, basic metabolic panel, complete blood count, urine culture, susceptibility studies, and infectious agent detections. You say that the enrollee was not enrolled in hospice until February 10, 2021. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the routine venipuncture (36415), basic metabolic panel (80048), complete blood count (85027), urine culture (87086), susceptibility studies (87186), and infectious agent detections by nucleic acid (U0003 and U0005) provided on February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystourethroscopy services provided on February 15,
2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the Medicare
rules have 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 CPT code.
We find that CPT codes 52441 and 52442 are not included in the list of covered surgical services in an
ambulatory surgical center. Based on this information, we decided that Medicare rules for coverage of the
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the
cystourethroscopy services provided on February 15, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit (99284) provided on October 5,
2020.
You asked the Plan to pay for the outpatient service. You say that you received a bill from a collection agency.
You also say that you were never billed by the provider. The Plan denied your request. The Plan says your
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on
the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on October 1, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the emergency room
visit (99284) provided on October 5, 2020.