Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve a core buildup and crown on tooth #30. We decided that the Plan does not have to pre-approve core buildups and crowns on teeth #28 and #31.
You asked the Plan to pre-approve core buildups and crowns on teeth #28, 30 and 31 for the enrollee. The Plan says that you have not submitted the required documentation to support the need for treatment.
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 core buildups and crowns when the services are medically necessary and reasonable.
We decided that the Plan has to pre-approve a core buildup and crown on tooth #30.
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 core buildups and crowns. Our reviewer says that a core buildup and crown on tooth #30 is medically reasonable and necessary for the enrollee in this case. Tooth #30 has an existing crown that appears to have recurrent decay around the margins. There appears to be sufficient support for the need for a replacement crown as well as a buildup. Our physician reviewer found that the enrollee's condition meets criteria for a core buildup and crown on tooth #30.
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 a core buildup and crown on tooth #30 have not been met. Therefore, we decided that the Plan has to pre-approve a core buildup and crown on tooth #30.
We also decided that the Plan does not have to pre-approve core buildups and crowns on teeth #28 and #31.
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 core buildups and crowns. Our reviewer says that core buildups and crowns on teeth #28 and #31 are not medically reasonable and necessary for the enrollee in this case. Tooth #28 has an existing two surface restoration, and does not appear to have more than 30% missing or damaged structure. In general crown restorations are a consideration when there is substantial loss of structure in excess of 50%. Buildups are only considered where additional support is required to retain a crown. As this is not the case for tooth #28, there is no medical necessity for a crown or buildup on #28. Tooth #31 has an existing crown in place, but no clear indication that the crown is defective. Our physician reviewer found that the enrollee's condition does not meet criteria for core buildups and crowns on teeth #28 and #31.
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 a core buildup and crown on tooth #30 have not been met. Therefore, we decided that the Plan does not have to pre-approve core buildups and crowns on teeth #28 and #31.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on October 27, 2018.You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.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 99239 is hospital discharge day management; more than 30 minutes.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 13, 2019 through August 20, 2019.You asked the Plan to pay forthe home infusion therapy. You say that S9328 is a valid code per the CMS website. The Plan denied your request. The Plan says S9328 has a status code of I which is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 13, 2019 through August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Somavert for the enrollee.
You asked the Plan to pre-approve Somavert. You say that the enrollee is well-controlled on the medication. The Plan denied your request. The Plan says drug coverage for the enrollee is limited to Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Somavert for the enrollee.
Benefits for Somavert may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for speech generating device (E2510) provided on July 30, 2019.
You asked the Plan to pay for the speech generating device. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service billed.
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 shows that the Plan made several attempts to obtain an itemized shipping/billing invoice for the items at issue in this appeal. The record does not contain a valid itemized shipping/billing invoice to indicate the specific supplies for the items in this case. Therefore, we decided that the Plan does not have to pay for speech generating device (E2510) provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Tetanus vaccination (90471 and 90714) provided on July 16, 2019.You asked the Plan to pay for the Tetanus vaccination. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says preventativeimmunizations and their administration are not a Medicare covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tetanus vaccination. Therefore, we decided that the Plan does not have to pay for a Tetanus vaccination (90471 and 90714) provided on July 16, 2019. Benefits for the Tetanus vaccination may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payformore than 30 minutes of hospital discharge day management services (99239) provided on October 24, 2019.You asked the Plan to pay forthe hospital discharge day management services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes.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 99239 is hospital discharge day management; more than 30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay formore than 30 minutes of hospital discharge day management services (99239) provided on October 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral exam (D0150) prophylaxis (D1110) bitewing x-rays x4 (D0274) provided by "the doctor" on August 2, 2019.You asked the Plan to pay forthe dental services. You say that you were not informed at theappointment that "the doctor" was not an in network provider.The Plan denied your request. The Plan says the services are covered benefits but the services are only covered when received from an in network provider.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 health plan contract specifically says services performed by an out of network dentist is not covered by the plan."The doctor" is not an in network provider. 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 forcomprehensive oral exam (D0150) prophylaxis (D1110) bitewing x-rays x4 (D0274) provided by "the doctor" on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forpolycarbonate(CPT V2784)lenses provided on September 4, 2019.You asked the Plan to pay forthe polycarbonatelenses. The Plandenied your request. The Plan says the polycarbonate is not a covered vision benefit.Medicare rules say that the use of polycarbonate or similar material (V2784) for indications such as light weight or thinness will be denied as a non-covered deluxe feature.We looked at the file and Medicare rules. Medicare says that the use of polycarbonate or similar material (V2784) for indications such as light weight or thinness will be denied as a non-covered deluxe feature. Therefore, we decided that the Plandoes not have to pay forpolycarbonatelenses provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by"the provider" from July 8, 2019 to September 26, 2019. You asked the Plan to pay forthe glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 8, 2019 to September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on May 6, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration as the services were billed correctly. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service.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 99153 is not supported in the record. Specifically, 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility and may only be billed by the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on May 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have a foot condition that only allows you to walk for a short amount of time due to your foot pain.The Plan denied your request. The Plan says this item is not a covered benefit.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.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.You asked the Plan to pre-approvethese services. You say that your physician told you that you met all of the clinical criteria for the procedure.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0466T is noncovered.The services at issue are hypoglossal nerve stimulation described by code 0466T. These services are not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvehypoglossal nerve stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be provided at a SNF level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by acute PMR or acute rehab nursing care. He may benefit from further PT and OT but does not require an intensive therapy program. With his dementia, he will not be able to participate and will not retain the learned functional skills. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 23, 2019 to October 11, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 23, 2019 to October 11, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97112, and 97116)
provided from June 4, 2019 to June 18, 2019.
You asked the Plan to pay for physical therapy services. You say that these services were not related to
hospice. The Plan denied your request. The Plan says payment for these services is the responsibility of
Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we
decided that the Plan does not have to pay for physical therapy services (97110, 97112, and 97116) provided
from June 4, 2019 to June 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forRadiology Services (71045) provided September 5, 2019 by "the provider". You asked the Plan to pay forthe radiology services. You say that this was a repeat service in the same day.The Plan denied your request. The Plan says the claim submitted was a duplicate.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 71045 is not supported in the medical record. Specifically, the claim submitted did not include the correct modifiers to denote a repeat service. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met.Therefore, we decided that the Plan does not have to pay forRadiology Services (71045) provided September 5, 2019 by "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that the requested incontinence briefs help keep the urine off of your clothes and from getting all over. You say that you have to change them at least twice a day to keep clean.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided thatthe Plan does not have to pay forthe office visit, trimming of skin lesion, and the nail debridement provided on April 16, 2019 to August 1, 2019 by the out of network provider.You asked the Plan to pay forthe debridement services. You say that you were unaware that a prior authorization was needed from the enrollee's primary care physician.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 has network providers available who can provide 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 forthe office visit, trimming of skin lesion, and the nail debridement provided on April 16, 2019 to August 1, 2019 by the out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrical stimulation rendered to "the beneficiary" by "the provider" on August 13, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 97014 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.The provider submitted a claim for procedure code 97014 (electrical stimulation). This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe electrical stimulation rendered to "the beneficiary" by "the provider" on August 13, 2019.