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

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 21, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that when you signed up for this Plan the agent advised that you would be covered 100% in-network and OON. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on April 21, 2021 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 6, 2020 and billed under codes 87486, 87496, 87498, 87541, 87581, 87640 and 87798.
You asked the Plan to pay for these lab services. You say that this claim should be paid. The Plan denied your request. The Plan says while a portion of this claim was paid, the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an Assisted Living Facility POS 13. Also, the laboratory results submitted indicate the specimen was collected on November 6, 202 and received by the lab on November 9, 2020. Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid in full due to a discrepancy with the POS code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 6, 2020 and billed under codes 87486, 87496, 87498, 87541, 87581, 87640 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet rich plasma injections (0232T).
You asked the Plan to pre-approve platelet rich plasma injections. You say that the enrollee has failed conservative treatment for her knee pain. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that platelet-rich plasma (PRP) will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds. 
We looked at the file and Medicare rules. The record shows that the PRP injections at issue were requested for knee pain. PRP injections are only covered for non-healing wounds. Based on this information, we decided that Medicare rules for coverage of platelet rich plasma injections have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma injections (0232T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 patient has Parkinson's disease and is living at home with increasing weakness Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on January 7, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on January 7, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you have been sitting for 9 months and need rehab so you can learn to use your new leg. The Plan denied your request. The Plan says you do not have the complexity of rehabilitation, medical management and nursing needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and complete series of intraoral x-rays (D0210) provided on March 25, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation and complete series of intraoral x-rays. You say that you were not aware that the treating provider was out-of-network. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have been exceeded. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 exam and comprehensive oral evaluation share a frequency of one procedure code every three years and full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a comprehensive oral evaluation and a panoramic x-ray on April 25, 2019 and your periodontal exam and comprehensive oral evaluation, and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and complete series of intraoral x-rays (D0210) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an E2300 power seat elevation system and the LUCI Safety System (which prevents tips, collisions, and falls).

You asked the Plan to pre-approve accessories for a power wheelchair. You say that these accessories are necessary inside and outside of the home. The Plan denied your request. The Plan says an E2300 power seat elevation system is not covered by Medicare. The Plan states that Medicare does not cover safety system accessories which are primarily used outside of the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules specifically state the E2300 power seat elevation system is not covered under any circumstance. The rules specifically state self-help or precautionary items are not covered.

Although these items may be helpful, neither Medicare nor the Plan covers these accessories. Therefore, we decided that the Plan does not have to pre-approve an E2300 power seat elevation system and the LUCI Safety System (which prevents tips, collisions, and falls).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 8, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the dentist you saw only looked over the x-rays and you only spent about 5 minutes with them. You also say that this procedure should have been paid for by your insurance. The Plan denied your request. The Plan says your benefit maximum for this service has been met.
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, comprehensive oral evaluation (D0150) are limited to one every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on March 22, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for a Vertiflex procedure have not been met because the requested procedure is experimental/investigational.
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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care, per day (99307) and the nail debridement (11721) rendered by the out-of-network (OON) provider on March 1, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 had network providers available who could have provided 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 for subsequent nursing facility care, per day (99307) and the nail debridement (11721) rendered by the out-of-network (OON) provider on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia service provided on February 3, 2020.

You asked the Plan to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure) (99100). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the procedure code 99100 has a status indicator of B on the Centers for Medicare and Medicaid Services (CMS) Physician Relative Value File.

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, we have confirmed that code 99100 has a bundled relationship with a Status Code of B and cannot be paid as billed. This code is always bundled into payment for other services and no separate payment is made per Medicare. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia service provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 gene testing (81241).
You asked the Plan to pre-approve F5 gene testing. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested genetic testing is considered not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare says testing of variants to the F5 and F2 genes are not covered except for pregnant patients. Therefore, we decided that the Plan does not have to pre-approve F5 gene testing (81241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that you were admitted to the current acute care hospital after a fall and incontinence. You were diagnosed with sepsis and acute kidney injury. The course was complicated by encephalopathy, hydronephrosis from renal stone requiring nephrostomy tube, acute respiratory failure. You appear to be currently unstable but improving, requiring short-term additional acute care services which can be safely completed at the current facility. You do not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time would not provide a clinical advantage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous, osteoperiosteal, or cartilage graft of the 
mandible or maxilla (D7950) and to pay more for the five surgical extractions (D7210 x5) provided on April 2, 
2021 by an OON provider. 
 
You asked the Plan to pay for the osseous, osteoperiosteal, or cartilage graft or pay more for the surgical 
extractions. You say that these services are covered under your plan. The Plan denied your request. The Plan 
says the osseous, osteoperiosteal, or cartilage graft is not covered. The Plan also says that these services were 
performed by a non-participating provider, and you are responsible for any difference between the Maximum 
Allowable Fee and the amount the provider bills you for the services. 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, osseous, osteoperiosteal, or cartilage 
graft of the mandible or maxilla (D7950) is not among those covered under this benefit. The contract also says 
that you are responsible for a 55% coinsurance for each extraction plus the difference between the billed and 
allowed amounts for services received out-of-network. Therefore, we decided that the Plan does not have to 
pay for the osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla (D7950) and to pay more for 
the five surgical extractions (D7210 x5) provided on April 2, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 20, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided while outpatient from March 12, 2021, to March 13, 2021.
You asked the Plan to pay for the self-administered drugs. You say that the Plan should pay the charge. The Plan denied your request. The Plan says self-administered drugs taken while outpatient are not covered by Medicare.
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 pay for the self-administered drugs provided while outpatient from March 12, 2021, to March 13, 2021.
Benefits for the self-administered drugs 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services and travel allowance provided on March 19, 2021 by an out-of-network provider.
You asked the Plan to pay for the laboratory services and travel allowance. You say that the Plan should pay this claim. The Plan denied your request. The Plan says authorization was not obtained prior to providing the enrollee the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 for the laboratory services and travel allowance provided on March 19, 2021 by an out-of-network provider.