Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment provided on November 19, 2020.
You asked the Plan to pay for the integrated biopsychosocial assessment. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 services 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 integrated biopsychosocial assessment provided on
November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and the unspecified preventive service (D1999) provided on December 8, 2020.
You asked the Plan to pay for the dental services. You say that this service is medically necessary. You also say that it is for non-cosmetic surgery for pain and chewing. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service. The Plan also says that this service is dental in nature.
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. Additionally, the services you are asking the Plan to pay for the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and the unspecified preventive service (D1999) provided on December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, cervical; without
contrast material (CPT code 72141) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the MRI. You say that you are in extreme pain and need the service for your
physician to diagnose the issue. The Plan denied your request. The Plan says there are in-network providers
that can provide the 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 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
MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141) to be provided by an outof-
network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis (22630, 22612) and spinal instrumentation
procedures on the spine (22840) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the requested surgery is not supported before a trial of treatment.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. There is no recent
and adequate trial of physical therapy for back pain documented in the chart. Our physician reviewer found that
the enrollee's condition does not meet Medicare criteria for these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve arthrodesis (22630, 22612) and spinal instrumentation procedures on the spine (22840) for
the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prosthetic eye care provided on May 1, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are not covered by Medicare or the Plan. Prosthetic eye care is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the prosthetic eye care provided on May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot inserts (CPT code L3000) and office services provided on February 13, 2019, by an out-of-network provider.
You asked the Plan to pay for foot orthotics. You say that you have not received your orthotics. The Plan denied your request. The Plan says they reached out to the provider who stated you knew the orthotics were not covered. The Plan states you signed a waiver that stated you would be liable for the services. The Plan states they verified that you had not picked up the orthotics. The Plan also states that the provider did not file the claim timely.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. The orthotics are not covered, and the Plan verified with the provider that you signed a waiver showing you would be liable for the services. Furthermore, your provider stated you did not pick up the orthotics. Therefore, we decided that the Plan does not have to pay for the foot inserts (CPT code L3000) and office services provided on February 13, 2019, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient hospital services provided from June 9, 2020, to June 12, 2020.
You asked the Plan to waive the cost share for the inpatient services. You say that you were placed in an intensive care unit instead of a regular room. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for inpatient hospital care. You have been asked to pay a 20% coinsurance until you reached your maximum out-of-pocket amount. The services fall 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 cost share for the inpatient hospital services provided from June 9, 2020, to June 12, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on June 5, 2020, through June 11, 2020.
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare rule for payment of this June 05, 2020 through June 11, 2020, claim has not been met.
The Plan must follow Medicare rules. Medicare rules say that if any E&M code that occurs on a day with a type "T" or "S" procedure does not have a modifier of 25, then edit 21 applies and the claim is returned to the provider. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Specifically, this claim includes CPT code 99284 which has a status indicator of V. This claim also includes code with status indicator S. CPT code 99284 was not billed with modifier 25 which means that Medicare rules for payment have not been met. Therefore, we decided that the Plan does not have to pay for the hospital services provided on June 5, 2020, through June 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285) provided on August 23, 2020.
You asked the Plan to pay for an emergency room visit. You say that this was billed correctly. The Plan denied your request. The Plan says code 99284 is more appropriate.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status): 1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 an emergency room visit Our reviewer says that the billing of 99285 is not supported. Our reviewer found the emergency room visit documents an acute illness with systemic symptoms, radiology and laboratory tests, and IV fluids. According to the Table of Risk, the documentation supports moderate level of risk, therefore, the correct Current Procedural Terminology code should be CPT 99284.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285) provided on August 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on September 9, 2020.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include the amount of time spent rendering the critical care services.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, critical care services are time based codes. The records submitted do not include the amount of time rendering these services. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 12, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the place of service on the claim must reflect the location of the enrollee 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 code. We looked at the file and the rules. The records provided do not indicate the enrollee's specimen was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology visits (CPT code 99213) to be
provided by an out-of-network provider.
You asked the Plan to pre-approve the visits. You say that the services are necessary. The Plan denied your
request. The Plan says there are in-network providers that can provide the 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 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
gastroenterology visits (CPT code 99213) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on November 18, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 services 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 nurse practitioner services provided on November 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 home health skilled nursing visits and 1008 home
health aide units.
You asked the Plan to pre-approve 20 home health skilled nursing visits and 1008 home health aide units. You
say that the enrollee continues to need home health services. The Plan denied your request. The Plan says home
health skilled nursing and aide visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 20 home health skilled nursing visits
and 1008 home health aide units. Our reviewer says that the requested home health services are not medically
reasonable and necessary. Our physician reviewer found the enrollee is a 55-year-old male with a past medical
history of a craniopharyngioma, diabetes mellitus and diabetes insipidus, hypothyroidism, Parkinson's disease
and a prior stroke who has been receiving home health nursing and nursing aide services. Based on the medical
records provided there is no documentation that skilled nursing services are required to effectively provide
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a
maintenance program to maintain the patient's condition and/or prevent deterioration. Approximately seven
months of home health services have already been provided and at this time it appears that custodial services
are indicated for the patient's needs. Therefore, the requested skilled nursing services and home health aide
services are not indicated 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 20 home health skilled nursing visits and 1008 home health aide units have not
been met. Therefore, we decided that the Plan does not have to pre-approve 20 home health skilled nursing
visits and 1008 home health aide units.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), the comprehensive periodontal evaluation (D0180), and the unspecified preventive service (D1999 x 2), provided from October 8, 2020, to November 9, 2020.
You asked the Plan to pay for the dental services. You say that you were diagnosed with periodontal disease. You say that your teeth cleaning exams are now considered periodontal prophylaxis, code D4910. You also say that now your teeth cleanings are not covered. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service. The Plan says that the unspecified preventive services are not listed as covered either. The Plan says that 1 periodontal exam is covered every 3 years. The Plan also says that the frequency limit has been exceeded.
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, periodontal maintenance and the unspecified preventive services are not among those covered under this benefit. Although periodontal exam is listed as a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a periodontal exam that you received on September 13, 2019, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), the comprehensive periodontal evaluation (D0180), and the unspecified preventive service (D1999 x 2), provided from October 8, 2020, to November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal paracentesis provided on
December 15, 2020.
You asked the Plan to waive the copayment for the abdominal paracentesis. You say that you went for a
sonogram and if there was fluid they would go in with a needle. You say that you should be billed for a
sonogram. The Plan denied your request. The Plan says the copayment 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 $375
copayment per visit.
You have been asked to pay a $375 copayment for the abdominal paracentesis. The abdominal paracentesis
falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The abdominal paracentesis is considered a surgical service. 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 abdominal paracentesis provided on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine
transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you are unable to afford
the cost of the commute to the treatment center. The Plan denied your request. The Plan says that this request
exceeds the benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits,
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we
decided that the Plan does not have to pre-approve an exception to the 50-mile limit for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the auricular nerve stimulation device.
You asked the Plan to pre-approve the requested nerve stimulator. You say that this is device has been cleared by the Food and Drug Administration and is covered by Medicare. The Plan denied your request. The Plan says the type of device at issue is not covered.
The Plan must follow Medicare rules. Medicare rules say that PFNS is not covered for any condition. The requested device is considered PFNS as the leads are placed to stimulate the subcutaneous distal distribution of an area of pain (indirectly stimulating the peripheral nerve). This type of nerve stimulator is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the auricular nerve stimulation device.