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

We decided that the Plan does not have to pay for the office visit (99202, 69209, 96127) and X-rays (70220,
73562, 70220, 73562) provided on September 10, 2019 to September 11, 2019.
You asked the Plan to pay for the physician and radiology services. You say that you moved and needed the
services. The Plan denied your request. The Plan says the services were not emergent or preauthorized.
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 has network providers
available who can provide 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 the office visit (99202, 69209, 96127) and X-rays (70220, 73562, 70220, 73562)
provided on September 10, 2019 to September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Tramadol HCL 50mg tablet medication (J8499).
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee as she suffers from Osteoarthritis of the lower lumbar spine. The Plan denied your request. The Plan says the member has a medical (MA) only policy with the Plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Tramadol HCL 50mg tablet medication (J8499).
Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided on September 29, 2019 by an out-of-network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that you would the Plan to reconsider payment for these services. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 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 for nursing facility care provided on September 29, 2019 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee needs continued rehab. The Plan denied your request. The Plan says that the enrollee has exhausted the SNF benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from December 16, 2019 through March 24, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, prophylaxis, comprehensive oral evaluation,
and panoramic x-ray provided on September 16, 2019. You asked the Plan to pay for the bitewings, prophylaxis, comprehensive oral evaluation, and panoramic x-ray. You say that this claim was processed incorrectly as Medicare covered dental services instead of non-Medicare covered preventive dental services. You also say that you are entitled to up to $525.00 every year for preventive and comprehensive dental services. The Plan denied your request. The Plan says the Plan reimbursed you for the entire allowance amount of $525.00 for services rendered on September 16, 2019 and September 30, 2019. The Plan also says that they will not reimburse you for any additional dental services because your contract clearly states that you are responsible for any amount over the dental allowance amount. 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 Plan offers a $525 allowance every year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual allowance benefit on September 30, 2019 and your annual allowance benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings, prophylaxis, comprehensive oral evaluation, and panoramic x-ray provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated ankle-foot orthosis (L1940) and accessory item (L2330).
You asked the Plan to pre-approve the orthosis and accessory item. You say that the enrollee has a history of falling, unsteadiness on feet, and muscle weakness, as well as balance problems while standing and walking. The Plan denied your request. The Plan says the documentation does not support the medical necessity criteria for a custom fabricated orthosis.
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 orthosis and accessory item. Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD/LCA for Medicare coverage of the custom fabricated ankle-foot orthosis and accessory item. The documentation does not reveal detailed objective muscle motor strength weakness, deformity or instability of the feet or ankles. There is no documentation of how this brace will help the patient benefit functionally or evidence of a need for stabilization for medical reasons. 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 orthosis and accessory item have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated ankle-foot orthosis (L1940) and accessory item (L2330).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services providedto the enrollee by an out-of-network provider on September 8, 2019, and October 6 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on September 8, 2019, and October 6 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the retreatment of previous root canal therapy. We decided that the Plan
does not have to pay for the cone beam CT capture and interpretation with limited field of view, therapeutic
parenteral drugs, and an unrecognized dental code (D0001).
You asked the Plan to pay for the retreatment of previous root canal therapy, cone beam CT capture and
interpretation with limited field of view, therapeutic parenteral drugs, and an unrecognized dental code
(D0001). You say that you called the Plan for referral to an in-network Endodontist and were given this
provider. You also say that the retreatment of the first root canal was necessary because of an infection. The
Plan says that these services are not covered benefits.
We decided that the Plan has to pay for the retreatment of previous root canal therapy.
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, which must be presented
clearly and accurately. The Plan covers dental services, including retreatment of previous root canal therapy
(D3347). Therefore, we decided that the Plan has to pay for the retreatment of previous root canal therapy.
We also decided that the Plan does not have to pay for the cone beam CT capture and interpretation with
limited field of view, therapeutic parenteral drugs, and an unrecognized dental code (D0001).
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 cone beam CT capture and
interpretation with limited field of view and therapeutic parenteral drugs are not among those covered under
this benefit. Code D0001 is an unrecognized dental code. Therefore, we decided that the Plan does not have to
pay for the cone beam CT capture and interpretation with limited field of view, therapeutic parenteral drugs,
and an unrecognized dental code (D0001).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on June 16, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. It has been determined that the billed inpatient discharge service, 99239, was denied because more than one discharge service was billed for the same date of service from the same provider under claim 820191760069112. According to CMS Policy, only one hospital discharge day management service is payable per patient per hospital stay. In addition, only the attending physician of record reports the discharge day management service. Since an inpatient discharge service has already been processed, subsequent discharge services will be denied. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on June 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on May 15, 2019. 
 
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other 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. 
 
We find that CPT code 95999 is not supported in the medical record.  Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on August 14, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered to the enrollee on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2751) provided on November 1, 2019.
You asked the Plan to pay for the dental service. You say that due to a mistake made by Social Security, you were removed from your dental plan. You say that you switched from your Medicare to your Survivor benefits. You also say that your dental coverage did not end until in the middle of November. The Plan denied your request. The Plan says you did not have active dental coverage as of September 1, 2019.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve 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. Additionally, the record shows your dental coverage was active from July 1, 2019 to August 31, 2019. Therefore, we decided that the Plan does not have to pay for the crown (D2751) provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nephrology services provided on August 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nephrology services. You say that these services are provided in good faith that you will be paid. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 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 for nephrology services provided on August 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 18, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 laboratory services. 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 laboratory services provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 27, 2019.You asked the Plan to payforthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.Medicare rules say that planscan 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 has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning services (CPT 99497) provided to the enrollee on September 11, 2019.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 this was not coded or billed correctly.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 99497 is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure already billed on this claim -CPT 99223. This code cannot be billed separately. 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 advance care planning services (CPT 99497) provided to the enrollee on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for chiropractic service. You say that Medicare guidelines were followed when treating this patient, and this service is covered.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for 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 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 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 medical services provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cardiac Diagnostic Testing services (78452, 93015, 96374, 96375, A9502, J2785) provided on October 16, 2019.
You asked the Plan to pay for the Cardiac Diagnostic Testing services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. The services could have been provided by in-network providers.
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 has network providers available who can provide 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 the Cardiac Diagnostic Testing services (78452, 93015, 96374, 96375, A9502, J2785) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided bythe physician on November 14, 2019.
You asked the Plan to waive the copayment for radiation therapy. You say that you disagree with the charges because you feel that they are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $60 copayment radiation therapy. You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies 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 radiation therapy provided bythe physician on November 14, 2019.