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

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee is a kidney transplant diabetic
and that both EMS calls were medical emergencies. You stated that the Plan should provide coverage of the
services provided. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on April 25, 2019 or on June 27, 2019. The
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays
for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and
pelvis, the CT of the thorax, and the chest x-ray provided on June 12, 2019.
You asked the Plan to pay for the radiology services. You say that the enrollee had signed and revoked hospice
services before they received the radiology services. The Plan denied your request. The Plan says the Medicare
hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to
the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending
physician services and all care unrelated to the terminal illness until the first day of the month following the
month in which hospice was revoked or discharged.
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 computed tomography (CT) scan of the abdomen and
pelvis, the CT of the thorax, and the chest x-ray provided on June 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown.
You asked the Plan to pre-approve the crown. You say that your dentist started working on your teeth, but you
need a crown in order for the dental work to be completed. The Plan denied your request. The Plan says this
service is not covered under your benefit package.
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 a
porcelain crown.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have multiple sclerosis and one of your legs is longer than the other. You say that you cannot walk comfortably without the requested orthotics. You also stated that you have had coverage of the orthotics previously. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (code D0274) and complete maxillary denture (code D5110) provided on October 2, 2019.
You asked the Plan to pay for the bitewings and complete maxillary denture. You say that about 3 years ago you were approved for a partial denture at this same office but never received it. The Plan denied your request. The Plan says these services have a limit on how often they can be paid for by the Plan. The Plan also says that the frequency limitations have already been reached.
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, bitewings are limited to once every 12 months per provider and complete dentures are limited to once in a 5-year period. The record shows that you received bitewings (code D0272) on March 25, 2019 and your bitewings benefit was then exhausted. The record also shows that you received an immediate maxillary denture on March 15, 2018 and your complete dentures benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings (code D0274) and complete maxillary denture (code D5110) provided on October 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that your blood sugar was low and the
ambulance responders saved your life. You say that you believe the bill for the ambulance services should be
covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 7, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367), the
endosteal implants (D6010 x 2), the bone graft at the time of the implant (D6104 x 2), and the bone
replacement graft, retained natural tooth, (D4263) provided from April 8, 2019 to May 8, 2019.
You asked the Plan to pay for the CT capture and interpretation, the implants, and the bone grafts. You say that
you contacted the Plan prior to receiving the services. You say that the none of the listed in network dentists
could provide the services. The Plan denied your request. The Plan says the dental services you received are
not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone
beam CT capture and interpretation (D0367), the endosteal implants (D6010 x 2), the bone graft at the time of
the implant (D6104 x 2), and the bone replacement graft, retained natural tooth, (D4263) provided from April
8, 2019 to May 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on June 7, 2019.

You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on June 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on August 21, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 21, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (D2950) and a root canal (D3320) for tooth # 29.You asked the Plan to pre-approve the dental services. You say that your dentist advised you needed a root canal, core build up, and a crown for tooth # 29. You say that your dentist advised these services are required to restore the full functionality of the tooth.The Plan denied your request. The Plan says core build up and a root canal are not covered services.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up and root canal are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the core build up (D2950) and a root canal (D3320) for tooth # 29.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 26, 2019.
You asked the Plan to pay for the lab services. You say that the lab testing that was rendered to the enrollee is
exclusive to this provider. The Plan denied your request. The Plan says the enrollee's 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. The Plan also says it is the provider's responsibility to
verify the member's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.
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 laboratory services provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you can only walk a few hundred feet without experiencing cramps in the bottoms of your feet. You say that your Doctor has insisted that you walk more in order to help your recovery from recent surgery. You stated that youneed the orthotics in order to continue walking.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physician's services to be provided the enrollee.  You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 pre-approved care. 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 out-of-network physician's services to be provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on September 30, 2019.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you saw this provider for an evaluation of worsening pain around tooth #5. You also say that you feel that this visit was necessary to find the reason for the pain you were experiencing. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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, exams are limited to two procedures per plan year. The record shows that you received a periodic oral evaluation on June 26, 2019 and a problem focused limited oral evaluation on July 2, 2019 and your exams benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride varnish (code D1206) provided on October 3, 2019.You asked the Plan to pay forthe topical application of fluoride varnish. You say that you were told by the office that these services would be covered. You also say that you should not be liable for these charges.The Plan denied your request. The Plan says this service is not covered by 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 excessof 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 forthe topical application of fluoride varnish (code D1206) provided on October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you are having surgery because of your recent cancer diagnosis. You say that after the surgery it will be difficult for you to stand for long periods of time therefore you need the shower chair.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing billed with procedure code 95999 on December 17, 2018.
You asked the Plan to pay for train of four testing. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because train of four testing is included in other neuromonitoring procedures and is not separately reportable.
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 train of four testing has a bundled relationship with intraoperative neuromonitoring of electromyography or motor evoked potentials (MEP), and is therefore not separately reportable. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of train of four testing billed separately with code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing billed with procedure code 95999 on December 17, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 9, 2019 by an out-of-network provider.Youasked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 has network providers available who can provide 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 forthe laboratory services provided on September 9, 2019 by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to pay fortissue transfer or rearrangement (14301) provided on July 25, 2019.You asked the Planto pay fortissue transferor rearrangement. You say that this procedure is documented in the record.The Plandenied your request. The Plansays this code is not supported in the record.The Plan follows Medicare rules. Medicare rules say that providers must report servicescorrectly. Procedures should be reported with the CPT code that describes the services performed.In this case, the definition of CPT code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.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 tissue transfer or rearrangement. Our reviewer says that CPT code 14301 is not supported. Our physician reviewer found the record does not contain evidence that adjacent tissue transfer or rearrangement of a defect greater than 30.1 sq cm was performed during this episode of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfer or rearrangement have not been met.Therefore, we decided that the Plandoes not have to pay fortissue transfer or rearrangement (14301) provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two retainer crowns, two pontics, and four gingival
irrigations.
You asked the Plan to pre-approve the retainer crowns, pontics, and gingival irrigations. You say that you can
only chew on one side of your mouth. You also say that your dentist said you would need a bridge or a partial
and without this you are left with no place to chew. The Plan denied your request. The Plan says these services
are not covered under your benefit package.
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 two
retainer crowns, two pontics, and four gingival irrigations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you have had arthritis for over twenty five years and have had several joint replacements. You say that it is difficult for you to walk and your podiatrist recommended that you try the orthotics. You stated that the orthotics have helped you considerably with your balance and the pain you experience in your feet. You say that you could not function without them. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.