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

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 15, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it is not right that you are being charged $500.00 because you did not use the ambulance. The Plan denied your request. The Plan says this is a non-covered service because ambulance is a transport benefit only.

The Plan follows Medicare rules. Medicare rules say that if an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. 

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 response and treatment with no transport. Our reviewer says that the ambulance services was not medically necessary. Our physician reviewer found you did not require emergency medical service care or transport due to being stable hemodynamically and having the ability to be treated as outpatient for your chronic issue. 

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 response and treatment with no transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740) for tooth #4 and core buildup, including any pins when required (D2950) for tooth #4.

You asked the Plan to pre-approve the crown and core buildup. You say that the procedures performed are considered major dental treatment. You also say that a core buildup was necessary to provide proper retention and restoration to the crown. The Plan denied your request. The Plan says that the records do not show that more than 50% of tooth #4 is lost due to a large defective restoration. The Plan also says that the core buildup is secondary to the crown which has not been approved.

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 crown and core buildup when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crown and core buildup. Our reviewer says that the criteria for coverage for a core buildup (D2950) and a crown restoration (D2740) for tooth #4 have been met. Our physician reviewer found tooth #4 has a large defective restoration comprising more than 50% of the coronal tooth structure. Our reviewer also found that a core buildup and crown restoration are medically reasonable and necessary to restore tooth #4 to normal function. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown and core buildup have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth #4 and core buildup, including any pins when required (D2950) for tooth #4.

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 pre-approve a partial lower denture (D5214).

You asked the Plan to pre-approve the dental item. You say that you need new bottom teeth. You say that you received a partial in 2018. You say that you had additions made to that until the teeth holding that partial had to be removed. You also say that you have gone without a partial denture until now. The Plan denied your request. The Plan says partial dentures are covered once every 5 plan years. The Plan also says that the frequency limit has 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 and lower partial denture is listed as a covered service, the frequency limit has been reached. The record shows that the Plan paid for a partial lower denture that you received on December 19, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve the Vertiflex Superion device. 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 Vertiflex Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device..
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on April 7, 2021.

You asked the Plan to pay for a comprehensive periodontal evaluation. You say that the service was necessary, and you want the Plan to cover it. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 a comprehensive periodontal evaluation (D0180) provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided June 15, 2020.

You asked the Plan to pay for the wrist hand orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the submitted claim is missing required documentation.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the medical documentation that was submitted does not demonstrate that the prescribing physician ever discussed the need for the requested equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis (L3916) provided June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 3, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.

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 $300 copayment per admission after the deductible is met for inpatient hospital care. 

You have been asked to pay a $300 copayment per admission after the deductible is met for inpatient hospital care. The service at issue falls within the inpatient hospital care 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 inpatient hospital care provided on August 3, 2020.
Appeal type: Practitioner Services
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 procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there are not enough studies on the Intracept procedure to show it is safe and effective.

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 remains experimental in cases of spinal surgery. More research is needed to show safety and efficacy of the device. 

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 pre-approve a mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).

You asked the Plan to pre-approve a lower partial denture. You say that you cannot use your old denture and need a new one. The Plan denied your request. The Plan says you have met 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 a lower partial denture once every 60 months.

We looked at the file and Medicare rules. The Plan provided documentation showing that a lower partial denture was previously covered on January 29, 2021. Based on this information, we determined that the Plan's frequency limit for the lower partial denture would be exceeded with the service in question. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 8, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 80307 and Healthcare Common Procedure Coding System (HCPCS) G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on November 18, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on November 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial or complete submucous resection services coded 30140 provided on December 8, 2020.

You asked the Plan to pay for the partial or complete submucous resection 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 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 CPT Code Manual definition of code 30140 is submucous resection inferior turbinate, partial or complete, any method.

We find that CPT code 30140 is not supported in the medical record. Specifically, the operative report did not include documentation of partial or complete submucous resection of the inferior turbinate, using any method; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the partial or complete submucous resection services have not been met. Therefore, we decided that the Plan does not have to pay for the partial or complete submucous resection services coded 30140 provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met in the current setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with acute hypoxic respiratory failure secondary to coronavirus pneumonia. The record indicates that the enrollee is improving but still requires ongoing cute care services. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (27220, 27197) provided on October 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.

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 CPT Code Manual definition of code 27220 is "Closed treatment of acetabulum (hip socket) fracture(s); without manipulation". The CPT Code Manual definition of code 27197 is "Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation".

We asked our coding 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 services. Our reviewer says that the use of codes 27220 and 27197 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of a "Closed treatment of acetabulum (hip socket) fracture(s); without manipulation", being performed on October 17, 2020, therefore code 27220 cannot be verified. The medical records provided do not include documentation of a "Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation", being performed on October 17, 2020, therefore code 27197 cannot be verified. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (27220, 27197) provided on October 17, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (87088, 87086, 84479, 84436, 80061, 81001,
36415, 83036, G0480, 80307, 83036, 84443, 85027, 81001, 36415, 80053) provided from June 9, 2020, to
April 2, 2021.

You asked the Plan to pay for laboratory services. You say that the enrollee's claims are being denied
incorrectly. The Plan denied your request. The Plan says that they have contacted the enrollee's other insurance
to request needed explanations of benefits (EOBs).

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.

The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has indicated
that they have only requested EOBs from the enrollee's other insurance. There is no documentation showing
that they have sent the bill to the primary insurance, instructed the provider to send the bill to the primary
insurance, or paid for these services and sent a bill for reimbursement to the primary insurance. Therefore, we
decided that the Plan has to pay for laboratory services (87088, 87086, 84479, 84436, 80061, 81001, 36415,
83036, G0480, 80307, 83036, 84443, 85027, 81001, 36415, 80053) provided from June 9, 2020, to April 2,
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with rails and a mattress for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria were not met.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed and rails is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with rails and a mattress for the enrollee.