Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to adjust the copayment for the telephone evaluation and management service (99442) provided on September 7, 2021. We also decided that the Plan does not have to waive the copayment for this service provided.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the copayment has been applied correctly to the service provided.

We decided that the Plan has to adjust the copayment for the telephone evaluation and management service (99442) provided on September 7, 2021. The service provided in this case was a telehealth visit with a specialist. The Plan contract states that a $10 copayment applies to telephonic and web-based medical consultation, diagnosis and/or treatment of urgent conditions. The contract does not specify that this copayment excludes specialist telehealth services. Therefore, we decided that the Plan has to adjust the copayment applied from $35 to $10 for the telephone evaluation and management service (99442) provided on September 7, 2021.

We also decided that the Plan does not have to waive the copayment for the telephone evaluation and management service (99442) provided on September 7, 2021. A telehealth service with a specialist was provided in this case. The Plan contract states that a $10 copayment applies to telephonic and web-based medical consultation, diagnosis and/or treatment of urgent conditions. 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 telephone evaluation and management service (99442) provided on September 7, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-rays (D0330) provided on December 8, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-rays. You say that you would not have gotten these procedures if you had known your insurance was not going to pay. You also say that you feel you should not have to pay because you told them if your insurance was not going to pay you would not have anything done. The Plan denied your request. The Plan says these services 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 items or services are not among those covered under this benefit. The only types of exams covered under your plan are routine oral exams and comprehensive oral exams. Problem focused limited oral evaluation does not fall under either of these types of exams. The only type of x-rays covered under your plan are bitewing x-rays. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-rays (D0330) provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vertiflex device placement surgery.
You asked the Plan to pre-approve these services. You say that you need this for pain relief. The Plan denied
your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare
due to insufficient evidence of efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device
is experimental and more research is needed. Our physician reviewer found that your condition does not meet
criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve vertiflex device placement surgery.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a cochlear implant for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that that the records do not show that the enrollee has limited benefit
from appropriate hearing aids in both ears.
The Plan must follow Medicare rules. Medicare rules say that a cochlear implant can be covered if the NCD
criteria is met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. There is a diagnosis of
bilateral sensorineural hearing loss (SNHL) as shown on testing August 18, 2021. The patient appears to have
the cognitive ability to use auditory clues. She communicated with a combination of spoken language and lip
reading. She also expressed willingness and ability to participate in an at-home aural rehabilitation program.
The patient was structurally suited for implantation. The otolaryngologist's note from August 18, 2021,
indicated that the bilateral outer and middle ear exams were normal, and that a temporal bone computed
tomography scan had been acquired showing bilateral patent cochleae were patent and normal temporal bone
anatomy. There are no stated contraindications to surgery. Temporal bone anatomy was normal as previously
noted, the patient has no evidence of active middle ear disease, and the patient expressed understanding of the
medical plan and the ability to participate in aural rehabilitation. Our physician reviewer found that the
enrollee's condition meets criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a cochlear implant for the enrollee.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on September 8, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70496 is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine physical exam received on July 13, 2021.

You asked the Plan to pay for the exam. You say that this is the first time seeing this provider. The Plan denied 
your request. The Plan says routine physical exam can only be performed once every calendar year.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Therefore, we decided that the Plan does not have to pay for a routine physical exam received on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-rays (D0330) provided on September 29,
2021.
You asked the Plan to pay for the panoramic x-rays. You say that you would like this claim to be reprocessed
and paid. The Plan denied your request. The Plan says the panoramic x-ray 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 items or services are not
among those covered under this benefit. The only type of x-rays that are covered under your dental benefit are
bitewing x-rays.
Therefore, we decided that the Plan does not have to pay for the panoramic x-rays (D0330) provided on
September 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on May 16, 2020, through June 14, 2020.
You asked the Plan to pay for the home health services. You say that you would like reconsideration because the documentation supports the services billed. The Plan denied your request. The Plan says the documentation submitted does not support the primary diagnosis.
The Plan must follow Medicare rules. The rules say that the content of the comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the patient's continuing need for home care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the home health services. Our reviewer says that Our physician reviewer found the diagnosis appears to have been chronic and stable. As such, the billing of Unspecified Atrial Fibrillation as the principle diagnosis is not supported. 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 home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided on May 16, 2020, through June 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided September
21, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you are trying to take care of your
teeth. The Plan denied your request. The Plan says you have exceeded the frequency limit 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. The Plan covers the
periodontal maintenance twice every 12 months.
We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal
maintenance was previously covered on February 16, 2021, and June 1, 2021. Based on this information, we
decided that the Plan's frequency limit for coverage of the periodontal maintenance has been exceeded.
Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided
September 21, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the Theraskin (Q4121) and application of skin grafts (15275 and 
15276) provided on April 26, 2021.

You asked the Plan to pay for the Theraskin (Q4121) and application of skin grafts (15275 and 15276). You 
say that the claim should be reprocessed with the medical records and issue the allowance due. The Plan denied 
your request. The Plan says that the denial of Theraskin is appropriate.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the Theraskin (Q4121) and application of 
skin grafts (15275 and 15276). Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found that the member meets the LCD coverage 
criteria due to a large defect.

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 Theraskin (Q4121) and application of skin graft (15275 and 15276) have 
been met. Therefore, we decided that the Plan has to pay for the Theraskin (Q4121) and application of skin 
grafts (15275 and 15276) provided on April 26, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital observation services (G0378) and specialist office visits (99213, 99204, 99212) rendered from August 3, 2021, to August 12, 2021.

You asked the Plan to waive the copayments for outpatient hospital observation services and specialist office visits. You say that you would like the category of this hospital changed to inpatient hospital stay and you disagree with the determination that the hospital stay was observation. You also say you did not choose to go into the hospital. You also say that you did need to be observed, but diagnosed with why you had the gastrointestinal (GI) bleed, since you never had that before. The Plan denied your request. The Plan says you were charged the correct cost sharing amount

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that except in an emergency, the hospital, your physician, or you must obtain prior authorization from the Plan for inpatient hospital care. Your contract with the Plan also says that enrollees must pay an $80 copayment for outpatient hospital services. Your contract with the Plan also says that enrollees must pay a $25 copayment each in-person specialist visit. 

You have been asked to pay an $80 copayment for outpatient hospital observation services. Outpatient hospital observation services falls within the outpatient hospital services benefit category. You have also been asked to pay a $25 copayment for each specialist office visit, for 8 visits, which is a total of $200 ($25 copayment x 8 visits = $200). Specialist office visits fall under the physician/practitioner services, including doctor's office visits 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 outpatient hospital observation services (G0378) and specialist office visits (99213, 99204, 99212) rendered from August 3, 2021, to August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a percutaneous auricular electrical nerve 
stimulator (electro-acupuncture device).

You asked the Plan to pre-approve electro-acupuncture device. You say that the enrollee would be an excellent 
candidate for use of this device to help with chronic pain and reduce the use of narcotics. The Plan denied your 
request. The Plan says this device is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that devices used for electro-acupuncture are not 
covered by Medicare for any indication. 

We looked at the file and Medicare rules. The requested use of this device is not covered by Medicare. Based 
on this information, we decided that Medicare rules for coverage of electro-acupuncture device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve use of a percutaneous auricular electrical 
nerve stimulator (electro-acupuncture device).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on July 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider, and we did not know that the facility failed to get preauthorization for this patient, so we treated this patient anyway. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained prior to the services being rendered.
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 a domiciliary or rest home visit (99336) provided on July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered
experimental/investigational.
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 Intracept procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and
efficacy.
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 Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for an intraoral periapical first radiographic image (D0220), a single bitewing x-ray (D0270), a 2D oral/facial photographic image (D0350), a crown (D2740), a prefabricated post and core in addition to a crown (D2954) and endodontic therapy (D3320) provided on October 5, 2020.
You asked the Plan to pay an additional amount for dental services. You say that you cannot pay the out-of-pocket amount owed and you disagree with the charges. You also say your new benefit of $3,000 for the year went into effect on October 1, 2020. The Plan denied your request. The Plan says additional reimbursement for this claim has been denied. The Plan also says you have exceeded your annual dental benefit maximum allowed amount.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. You received dental services on June 22, 2020 and the Plan paid the allowed amount of $50. You received dental services on July 22, 2020 and the Plan paid the allowed amount of $1,155. You received dental services on August 28, 2020 and the Plan paid the allowed amount of $727. You received dental services on September 9, 2020 and the Plan paid the allowed amount of $52. You received dental services on October 5, 2020 and the Plan paid an allowed amount of $16.
The records show that you met your annual maximum benefit for dental services of $2,000 on October 5, 2020 ($50 + $1,155 + $727 + $52 + $16 = $2,000). The Plan confirmed that the policy that terminated on September 30, 2020, had the annual maximum of $3,000 and your new policy effective October 1, 2020 had a new annual maximum of $2,000. The Plan also confirms that the annual maximum does not start over when you have a Plan change during the year, the amount only changes. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for an intraoral periapical first radiographic image (D0220), a single bitewing x-ray (D0270), a 2D oral/facial photographic image (D0350), a crown (D2740), a prefabricated post and core in addition to a crown (D2954) and endodontic therapy (D3320) provided on October 5, 2020.