Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a fasciectomy (26125-F3) provided on October 23, 2020.
You asked the Plan to pay for a fasciectomy. You say that this code is supported. The Plan denied your request. The Plan says that this procedure is not documented.
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 26125-F3 is fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure). Modifier F3 indicates left hand, fourth digit. 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 a fasciectomy. Our reviewers says that this code is supported. Our physician reviewer found the operative report documents a fasciotomy and tendon sheaths freed was performed on the left ring finger, therefore CPT 26125 is confirmed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fasciectomy have been met. Therefore, we decided that the Plan has to pay for a fasciectomy (26125-F3) provided on October 23, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010) for tooth # 30.
You asked the Plan to pre-approve the dental service. You say that this is medically necessary. The Plan denied your request. The Plan says surgical placement of an implant body 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010) for tooth # 30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 8, 2021 by an out
of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 the physician services provided on January 8,
2021 by an out of network (OON) provider.
Your complaint about the OON provider being your primary care physician 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reconsider at the in-network level the prosthetic limb and supplies
provided on January 12, 2021, by an OON provider.
You asked the Plan to reconsider at the in-network level the prosthetic limb and supplies. You say that you
would like this claim reprocessed at the in-network level. The Plan denied your request. The Plan says this
claim processed correctly.
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 only reimburse up to $5,000 for services received using the POS option.
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 has reimbursed the
maximum amount of $5,000. We found no exception that would require the Plan to reconsider at the in network
level these items/services. Therefore, we decided that the Plan does not have to reconsider at the in network
level the prosthetic limb and supplies provided on January 12, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on November 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 the physician services provided on November 25, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 2 and 4, and a pontic (D6245) for tooth # 3.

You asked the Plan to pre-approve the dental services. You say that you were having problems with your tooth. You say that you need to have the tooth extracted. You say that you will also need a cap on both sides to ensure that your teeth would not shift. You also say that you have explored all other options, and this is the only other one available. The Plan denied your request. The Plan says retainer crown is not listed as a covered service. The Plan says that pontic is not listed as a covered service either. The Plan also says if a dental item or service is not listed in the benefit chart then it is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 2 and 4, and a pontic (D6245) for tooth # 3.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2750), post and core in addition to a crown (D2954), a nerve treatment (D3320), and a filling (D2392).

You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says routine preventive and comprehensive dental services are not covered by Medicare.

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 the crown (D2750), post and core in addition to a crown (D2954), a nerve treatment (D3320), and a filling (D2392).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the Truxima injection provided on March 2, 2020.
You asked the Plan to pay for the services provided. You say that the code was approved for the procedure
requested. The Plan denied your request. The Plan says that the billed drug was not submitted with an approved
diagnosis code.
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.
We looked at the file and the rules. The records show that Rituximab (Truxima) injection was billed with a
diagnosis of unspecified non-Hodgkin's lymphoma (C85.90). The rules show that this diagnosis code is
payable for the billed drug. The file also includes a prior authorization for the injection at issue. Although
authorization is not a guarantee of payment, there is no clear rule or policy provided that would preclude
payment with the billed diagnosis code. The Plan has not made reasonable and diligent efforts to gather and
forward to us information regarding their decision to deny your request for the injection. Therefore, we decided
that the Plan has to pay for the Truxima injection provided on March 2, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis provided August 27, 2020.
You asked the Plan to pay for the knee orthosis. You say that you would like this claim reviewed for medical
necessity. The Plan denied your request. The Plan says the documentation is missing required information.
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 a valid proof of delivery for the supplies provided in this case. Review of the file
shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific
supplies; therefore, the billed supply code cannot be verified. 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 knee orthosis provided August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture provided on January 5, 2021 by an OON provider.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you would like to appeal these services. The Plan denied your request. The Plan says you self-referred to an OON dentist. The Plan also says that non-emergency services provided by an OON provider are not available with 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture provided on January 5, 2021 by an OON provider.
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 the enrollee needs a LTACH admission for continual vent weaning to include pulmonary toileting and respiratory treatments, daily nutritional/dietary management and daily weights, TPN with daily labs, rehab for PT/OT/ST, daily visits from the physician and specialty consults including pulmonology, nephrology and infectious disease. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6750) for teeth # 28 and 29, and a pontic (D6240) for tooth # 30.
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontic 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 pre-approve retainer crowns (D6750) for teeth # 28 and 29, and a pontic (D6240) for tooth # 30.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 14,
2020, to December 13, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's
condition no longer required daily skilled services at an inpatient SNF 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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 14, 2020, to December 13,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation and follow up visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the consultation and follow up visit. You say that when you signed up for this plan you were told that even though you live in Las Vegas you would be able to receive non-emergency treatment in southern Utah. You would like the options for medical treatment in St. George, Utah. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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. Therefore, we decided that the Plan does not have to pre-approve the consultation and follow up visit to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on October 15, 2020 by an OON provider.
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that there is no authorization on file.
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 the home visit provided on October 15, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate (conscious) sedation (99152) provided September 28, 2020.

You asked the Plan to pay for moderate sedation. You say that please reprocess for additional payment of services rendered. The Plan denied your request. The Plan says the records do not support service 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 CPT Code Manual definition of code 99152 is Moderate Sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness, and physiological status, initial 15 minutes of intra-service time, patient age 5 years or older.

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 moderate sedation. Our reviewer says that the documentation submitted does not meet the Medicare criteria. Our physician reviewer found the procedure report does not include documentation of the presence of an independent trained observer during the procedure. All criteria described in the description of the CPT code must be clearly documented to confirm the procedure has been performed. In this case, the independent observer was not documented and cannot be confirmed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of moderate sedation have not been met. Therefore, we decided that the Plan does not have to pay for moderate (conscious) sedation (99152) provided September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) and two surgical
extractions (D7210 x2).
You asked the Plan to pre-approve the mandibular partial denture and surgical extractions. You say that you
would like these services to be approved for coverage. The Plan denied your request. The Plan says these
services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
mandibular partial denture (D5212) and two surgical extractions (D7210 x2).