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

We decided that the Plan has to pay 50% of the cost up to the maximum allowance for the custom fabricated
abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided
February 19, 2021.

You asked the Plan to pay 50% of the cost up to the maximum allowance for the custom fabricated abutment
and abutment supported crown. You say that you would like the services covered. The Plan denied your
request. The Plan says that the services are not covered under your benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). Your contract with the Plan says that you pay 50% for
comprehensive dental services up to a maximum $1,250 allowance. It does not say in clear and accurate terms
that only specific services are covered under the comprehensive dental allowance.

We looked at your contract with the Plan. We sent a request for information to the Plan for additional
information about services covered under the Plan and did not receive a response with the requested
information. Based on the information provided in the Plan contract, we did not see clear evidence that
abutments or abutment supported crowns are not covered under the enrollee's comprehensive dental coverage.
This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore,
we decided that the Plan has to pay 50% of the cost up to the maximum allowance for the custom fabricated
abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided
February 19, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions (RACZ procedure) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure has not been proven as effective as other standard treatments of lower back pain and spine disorders.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure. Therefore, the request is deemed medically unnecessary and unreasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lysis of epidural adhesions (RACZ procedure) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a truck lift (A9270) to transport your wheelchair.

You asked the Plan to pre-approve a truck lift. You say that the wheelchair weighs 300 pounds, and you cannot go in and out of the vehicle without your daughter's assistance, but your daughter is 58 years old with a heart condition and cannot carry you in and out of the vehicle. The Plan denied your request. The Plan says this item does not meet the definition of DME and is not primarily and customarily used to serve a medical purpose. The provider is not a Medicare certified DME provider.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a truck lift (A9270) to transport your wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020.

You asked the Plan to pay for the laboratory services. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services are not payable as billed

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. In addition, the documentation does not support evidence of an established relationship between the ordering physician and the enrollee. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that the additional PT visit are
medically necessary. The Plan denied your request. The Plan says there is no evidence that the member is
making progress towards goals. The notes do not show modification to the treatment plan or treatment goals.
There has been adequate time to instruct and transition to a home program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has
been instructed in and is compliant in a home exercise program. The requested services are not part of a
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0180, D7210) received December 9, 2020 from the out-of-network provider.
You asked the Plan to pay for the dental services (D0180, D7210). You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says services are covered with providers in the Plan network only.
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. The Plan does not provide coverage for dental services received outside of the Plan's network. Therefore, we decided that the Plan does not have to pay for the dental services (D0180, D7210) received December 9, 2020 from the out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the emergency transport with basic life support (A0429-RH) provided on December 14, 2020.
You asked the Plan to pay for the transportation services. You say that you fell twice the day before. You also say that your spouse was not comfortable taking you to the hospital by himself. The Plan denied your request. The Plan says the criteria for coverage of these services has not been met. The Plan says that you could have been safely transported by other means of transportation. The Plan also says that the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Specifically, the record does not show that other means of transport (other than ambulance) would have endangered your health. In this case, a prudent layperson would not believe that without immediate medical attention there would have been serious jeopardy to your health. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the emergency transport with basic life support (A0429-RH) provided on December 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on
September 9, 2020.

You asked the Plan to pay for the therapeutic procedure. You say that you feel the services were billed
correctly. The Plan denied your request. The Plan says the services are not payable as 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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation indicates
that the service was performed by a physical therapist assistant in a home health or hospice setting. There is a
more appropriate code to be billed for these services. Based on this information, we decided that Medicare
rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not
have to pay for the therapeutic procedure coded 97110 provided on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal manipulation, therapeutic services, hip strapping, and electrical stimulation provided by a chiropractor on September 24, 2020.

You asked the Plan to pay for chiropractic services. You say that the Plan has paid for these same services in the past. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare when performed by a chiropractor and the Plan's benefit for routine chiropractic care was exhausted.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan offers a routine chiropractic benefit in excess of Medicare's coverage. The Plan covers 30 routine chiropractic visits each calendar year.

The records show that the service at issue is not manual manipulation of the spine. Furthermore, the Plan's benefit for routine chiropractic services was exhausted. Therefore, we decided that the Plan does not have to pay for extraspinal manipulation, therapeutic services, hip strapping, and electrical stimulation provided by a chiropractor on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and the intraoral - periapical first radiographic image (D0220) received February 11, 2021.

You asked the Plan to pay for the dental services (D1206, D0220). You say that you are covered for these services and should not have to pay anything on the claim. The Plan denied your request. The Plan says you do not have coverage for the fluoride varnish or the periapical first radiographic image.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and the intraoral - periapical first radiographic image (D0220) received February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating provider on January 7, 2021.
You asked the Plan to waive the copayment for an office visit. You say that the Plan was waiving copayments due to Covid-19, and this should be waived. The Plan denied your request. The Plan says the correct copayment has been applied. The Plan says that copayments were waived from May 11, 2020, through September 30, 2020. The Plan says that these services happened outside of those dates.
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 $15 copayment for physician/practitioner services/in-network/primary care physician.
You have been asked to pay a $15 copayment for an office visit. The correct copayment has been applied to the services that were provided. An office visit falls within the physician/practitioner services/in-network/primary care physician 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 an office visit provided by a participating provider on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on January 11, 2021.

You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 99153 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional component/technical component of 3. CPT code 99153 was established as a practice expense-only code meaning there is no work component relative value unit (RVU) associated with that service 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 the moderate sedation services coded 99153 provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and cone beam
CT capture and interpretation provided on January 22, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation and cone beam CT capture and
interpretation. You say that you were referred to this provider by your dentist, regarding a wisdom tooth that
needs to be surgically removed. 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 pay for the
problem focused limited oral evaluation and cone beam CT capture and interpretation provided on January 22,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical or manipulative therapy performed for
maintenance rather than restoration services received from January 22, 2018, to December 30, 2020.

You asked the Plan to pay for the physical or manipulative therapy performed for maintenance rather than
restoration services. You say that you would like to be reimbursed for your copays. The Plan denied your
request. The Plan says the services received are not payable.

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 S8990 is physical or manipulative therapy performed for
maintenance rather than restoration.

We find that CPT code S8990 is not supported in the medical record. Specifically, this code billed has a status
code of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment of these services. This means that the services received from
August 26, 2020, to December 30, 2020, are not payable as billed.

The record shows that a claim for the physical or manipulative therapy performed for maintenance rather than
restoration services provided January 22, 2018, to June 27, 2019, were not filed until February 12, 2021. This
means that more than one calendar year from the date of service had passed before a claim was filed.

Based on this information, we decided that Medicare rules for coverage of the physical or manipulative therapy
performed for maintenance rather than restoration services have not been met. Therefore, we decided that the
Plan does not have to pay for the physical or manipulative therapy performed for maintenance rather than
restoration services received from January 22, 2018, to December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair (A9270).
You asked the Plan to pre-approve a chair. You say that you cannot afford the item and it should be covered by Medicare. The Plan denied your request. The Plan says the item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a chair (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the provider is well aware of your condition and has been treating you very closely. The Plan denied your request. The Plan says there are providers you can go to in your 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cataract surgeries performed by an out of network provider on July 22 and August 5, 2020.

You asked the Plan to waive the coinsurance for cataract surgeries. You say that the charges at issue are exorbitant and you are not prepared to pay them. The Plan denied your request. The Plan says the correct coinsurance was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% coinsurance for each out of network Medicare-covered outpatient surgery or procedure.

You have been asked to pay $1,436.09, or 40% of the Medicare-allowed charge of $3,590.23, for each one of
two cataract surgeries. Cataract surgeries fall within the "Outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers" 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 coinsurance for cataract surgeries performed by an out of network provider on July 22 and August
5, 2020.