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

We decided that the Plan does not have to pre-approve twenty-four (24) additional routine transportation trips
(A0120).
You asked the Plan to pre-approve twenty-four (24) additional routine transportation trips. You say that you
want the Plan to pre-approve additional trips. The Plan denied your request. The Plan says you have utilized the
maximum number of transportation trips allowed per year.
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 24 trips per year.
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 twenty-four (24) additional routine transportation trips
(A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81201, 81408, 81404, 81403, 81405, 81406, 81298, 81308, 81317, 81162, 81292, 81479, and 81321 provided April 9, 2020 to April 29, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

We find that CPT 81201, 81408, 81404, 81403, 81405, 81406, 81298, 81308, and 81317 are not supported in the medical record. Specifically, the services were billed with an inappropriate modifier. 

The testing coded 81162, 81292, 81479, and 81321 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 laboratory services coded 81201, 81408, 81404, 81403, 81405, 81406, 81298, 81308, 81317, 81162, 81292, 81479, and 81321 provided April 9, 2020 to April 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) provided March 3, 2021.
You asked the Plan to pay for the osseous surgery. You say that you disagree with the denial and believe the service should be covered with 50% coinsurance. The Plan denied your request. The Plan says this service is was not covered under your benefits at the time of 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. Therefore, we decided that the Plan does not have to pay for the
osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant (D4260) provided March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479, 81407, 81408, 81404 and 81286) provided January 29, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this type of lab testing is non-covered.
The Plan must follow Medicare rules. Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients, for suspected or documented cardiovascular-respiratory disease. We looked at the file and Medicare rules. The services at issue are cardiovascular risk panels and are not covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479, 81407, 81408, 81404 and 81286) provided January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided April 12, 2021.

You asked the Plan to pay for the limited oral exam. You say that you required additional services due to having a small mouth. The Plan denied your request. The Plan says you have exceeded frequency limits 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 limited oral exam once per plan year. 

We looked at the file, and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on January 28, 2021. Based on this information, we determined that the Plan's frequency limit for the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November
4, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was 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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 4, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on March 18, 2021.

You asked the Plan to pay for the dental services. You say that you were instructed to go to this establishment. You say that you did not know what procedures would be necessary to correct your problem. You say that you have very limited resources to pay for these services. You also say that you should have been informed that the services you needed were not covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that panoramic x-ray is not listed as a covered service either.

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 limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention (D2951) provided on April 21, 2021.
You asked the Plan to pay for the pin retention. You say that you cannot afford to pay these charges. The Plan
denied your request. The Plan says this service is not a covered benefit 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 pin retention (D2951) provided on April 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the SNF services. You say that the enrollee needs strengthening and conditioning. You say that the enrollee meets the criteria for coverage of SNF care. The Plan denied your request. The Plan says the enrollee does not need daily skilled services in an inpatient setting. The Plan says that the enrollee's rehabilitation and medical needs can be met with part-time skilled services at an alternate level of care.

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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be functioning at/near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs can be provided at a lower level 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive eye exam you had on April 27, 2021.
You asked the Plan to waive the copayment for the comprehensive eye exam. You say that you do not think you should have to pay a copayment because you thought you were just having a routine eye exam. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the medical records show that you had a comprehensive new patient exam with medical diagnosis of suspected glaucoma, anisometropia, and cataracts. That is why this is a medical eye exam, not a routine one.
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 $20 copayment for eye exams to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $20 copayment for the comprehensive eye exam. The medical records from this visit clearly show that you had a comprehensive medical eye exam, not a routine eye exam. That is why the comprehensive eye exam falls within the eye exams to diagnose and treat diseases and conditions of the eye 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 the comprehensive eye exam you had on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.
You asked the Plan to pre-approve facet joint interventions. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee is known to have untreated radiculopathy or neurogenic claudication which is a contraindication to facet joint interventions.
The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain clinical conditions. 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 facet joint interventions. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint interventions. Our physician reviewer found the enrollee reported 100% relief of low back pain following a caudal epidural steroid injection. However, this is not consistent with the facet joint being the source of pain. The enrollee is known to have untreated radiculopathy or neurogenic claudication, which is a contraindication to facet joint interventions. There is clear evidence of non-facet pathology that could explain the source of the enrollee's pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint interventions have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crowns (D6058 x2), custom fabricated abutments (D6057 x2), surgical placement of implant body (D6010 x2), autogenous connective tissue graft procedure (D4273 x2), and other drugs and/or medicaments (D9630 x2).
You asked the Plan to pre-approve abutment supported porcelain/ceramic crowns, custom fabricated abutments, surgical placement of implant body, autogenous connective tissue graft procedure, and other drugs and/or medicaments. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve abutment supported porcelain/ceramic crowns (D6058 x2), custom fabricated abutments (D6057 x2), surgical placement of implant body (D6010 x2), autogenous connective tissue graft procedure (D4273 x2), and other drugs and/or medicaments (D9630 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and follow-up office visits to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
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, care that cannot be provided by network providers, kidney dialysis services when you are out of the service area for a short time, and when you first join the Plan and can establish an existing relationship with the requested provider. 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 a consultation and follow-up office visits to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device.
You asked the Plan to provide a pneumatic compression device (E0676). You say that you need this device. The Plan denied your request. The Plan says this device is being ordered for deep vein thrombosis prevention for an upcoming elective surgery and therefore not covered.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Items used for a preventative service are excluded from coverage. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this device is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to provide a pneumatic compression device
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the ventilator. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that ventilators are covered for the indications established in the applicable LCD.
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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 62-year-old female with COPD with hypoxia, hypercarbia, alveolar hypoventilation, and severe obesity. Recent notes show that she tolerated supplemental oxygen and BiPAP. Based on the objective documentation of the arterial blood gases (ABG) test findings on BiPAP and insufficient evidence to support a full ventilator, this request for such will be considered not medically necessary at this time. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical traction equipment (E0855).

You asked the Plan to pre-approve cervical traction equipment (E0855). You say that your doctor would not have ordered this device if it were not medically necessary. The Plan denied your request. The Plan says the records do not show you have met the requirements of being shown how to use the device and that you are able to tolerate the device.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The record does not show the device was demonstrated or that you have TMJ, distortion of the lower jaw or neck, or the necessity for greater than 20 pounds of traction. Based on this information, we decided that Medicare rules for coverage of cervical traction equipment (E0855) have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical traction equipment (E0855).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88350, 88346, 83520, 86140) provided September 4, 2020.
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover Prometheus IBD sgi Diagnostic tests. We looked at the file and Medicare rules. The lab services at issue are non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88350, 88346, 83520, 86140) provided September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87506) provided on February 7, 2021.
You asked the Plan to pay for infectious agent detection. You say that this was billed correctly. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.
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 pay for infectious agent detection. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation, such as provider records, to explain why testing via standard stool cultures would not have been sufficient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection (87506) provided on February 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by the OON provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by the OON provider.