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

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered by an OON provider.
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that the sales representative advised that you could see your dentist and the services would be covered. You also say that you are now being told your dentist is not in-network. The Plan denied your request. The Plan says services are only covered by your Health Plan for in-network dentists. The Plan also says that the provider you have requested to see is OON.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be rendered by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the root canal (D3330) provided on December 31, 2020.
You asked the Plan to pay for the dental services. You say that you had a temporary crown placed on tooth # 3 on December 18, 2020. You say that you had a permanent crown placed on tooth # 3 on January 7, 2021. You say that you should have been billed for the permanent crown in January, not December. You say that only $494 was applied to the crown as your benefit limit had been reached. You also say that you would like the
$494 payment to be applied to the root canal that you received on December 31, 2020 instead. The Plan denied your request. The Plan says there is a $600 allowance per quarter for comprehensive dental services. The Plan says that the $2,400 accumulated allowance has been exhausted.
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 services that you received are not listed as covered services. Additionally, the accumulated annual allowance of $2,400 has been exhausted. The record shows that the Plan recouped $275 for services rendered on December 18, 2020 and applied it to the non-covered services provided on December 31, 2020.
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the root canal (D3330) provided on December 31, 2020.
Your complaint about being charged for the permanent crown in December 2020 instead of January 2021 is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a sleep study (95806) provided December 30, 2020.
You asked the Plan to waive the coinsurance for the sleep study. You say that you were told the copayment would be waived and you didn't need the sleep study according to your specialist. The Plan denied your request. The Plan says the service was rendered, and the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for sleep studies. You have been asked to pay a 20% coinsurance for the sleep study. The sleep study falls within the sleep studies 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 coinsurance for a sleep study (95806) provided December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does nothave to pre-approve32 additional routine transportation trips.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says you have exhausted the 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 24 one-way 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 Plandoes not have to pre-approve32 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the panoramic x-ray (D0330), the periodic oral evaluation (D0120), and the bitewing x-ray (D0274) provided on January 6, 2021.
You asked the Plan to pay the in network rate for the panoramic x-ray. You say that you confirmed with both the Plan and the provider's office that they were in network prior to your appointment. You also say that this claim should be reprocessed and paid at the in network rate. The Plan denied your request. The Plan says panoramic x-ray is not listed as 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 panoramic x-ray not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay the in network rate for the panoramic x-ray (D0330), the periodic oral evaluation (D0120), and the bitewing x-ray (D0274) provided on January 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the drug is not eligible for a tier exception.
The Plan must follow Medicare rules. Medicare rules say that Part B covered drugs are not eligible for Part D tier exceptions. We looked at the file and Medicare rules. The requested drug is covered by Part B Medicare and not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Tacrolimus.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2311, E2313, E2377).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed herself indicates that the patient can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2311, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient hospital care provided December 10, 2020.

You asked the Plan to pre-approve the inpatient hospital care. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says that a corrected claim is needed.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Insufficient documentation was provided to the IRE to support the denial. The redetermination letter issued by the plan notes a provider billing error, but no details or rationale were provided. The plan did not cite any CMS policies or rules to support the denial issued. Therefore, we decided that the Plan has to pre-approve inpatient hospital care provided December 10, 2020. 

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: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services (A0427 and A0425) provided on October 13, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the ambulance services were medically necessary. The Plan denied your request. The Plan says that the member was hemodynamically stable and could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the member is elderly with acute complaints of dizziness and vomiting. It is possible that they could become unstable at any time and acute coronary syndrome also needs to be ruled out. Our physician reviewer found it would be medically appropriate to transport the member via ambulance services to monitor their vitals and provide CPR if necessary en route. 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 ambulance services have been met. Therefore, we decided that the Plan has to pay for ambulance services (A0427 and A0425) provided on October 13, 2020.
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 pay for surgical assistant services (27447-AS-LT) provided November 16, 2020.
You asked the Plan to pay for surgical assistant services. You say that this code is payable and therefore the claim should be paid. The Plan denied your request. The Plan says the provider type is not recognized by Medicare for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (27447-AS-LT) provided November 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Intravitreal injections (67028) provided June 29, 2020 to August 18, 2020.
You asked the Plan to waive the copayments for the Intravitreal injections. You say that you had these services performed in Florida and the copayment was less. The Plan denied your request. The Plan says the correct copayment was applied based on the setting the services were provided at.
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 $250 copayment for outpatient surgical services. You have been asked to pay 2 $250 copayments (for a total of $500) for the Intravitreal injections. The Intravitreal injections falls within the outpatient surgical services 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 Intravitreal injections (67028) provided June 29, 2020 to August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for 45 additional trips for routine transportation.
You asked the Plan to provide coverage for 45 additional trips for routine transportation. You say that you do not have a car or someone to take you to your physical therapy visits. The Plan denied your request. The Plan says our benefit only allows 36 trips for this service. You have exceeded 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 36 one-way trips per year.
We looked at your request, the records in the case file, and the rules. The file shows that the Plan provides coverage for up to 36 one-way trips for routine transportation. 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 provide coverage for 45 additional trips for routine transportation.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electromyography provided on November 10, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the procedure is
not covered for the diagnosis listed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 95867 is needle electromyography; cranial nerve supplied muscle(s), unilateral. We find that CPT code 95867 was billed with a diagnosis of fracture of mandible, unspecified, initial encounter for open fracture (S02.609B). We looked at the file and the rules. This diagnosis is not covered for the billed procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the electromyography provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you performed the tests ordered by the referring physician in good faith. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 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 laboratory testing provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 6 additional physical therapy visits.

You asked the Plan to provide 6 additional physical therapy visits. You say that the enrollee would benefit from additional physical therapy visits. The Plan denied your request. The Plan says they will approve 4 of the requested 10 OP PT but the remaining 6 are not medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 provide 6 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior therapy extensive outpatient therapy visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide 6 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 7, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed.

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued referral to an out-of-network dermatologist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are no out-of-network benefits.

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. The plan has approved two transitional visits to this provider, which will be sufficient for your needs. Therefore, we decided that the Plan does not have to pre-approve a continued referral to an out-of-network dermatologist.