Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you had a stroke and have difficulty standing in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99053) provided April 14, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed is not separately 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.
We find that CPT code 99053 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, the billed code has a status of "B" and payment is always bundled with another service. Based on
this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for anesthesia services (99053) provided April 14,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on August 2, 2021.

You asked the Plan to pay for the pain management services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.

We looked at the file and Medicare rules. In this case, there were no medical records provided for review to
determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the
pain management services provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to issue reimbursement for the skin tissue procedures (17999) provided from
October 4, 2021, through November 8, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of
network provider, without prior authorization or a referral.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for these services by a contract provider. The file does not show that the Plan provided
notice that these services would not be covered. Under Medicare rules, this means these services are considered
approved by the Plan. Therefore, we decided that the Plan has to issue reimbursement for the skin tissue
procedures (17999) provided from October 4, 2021, through November 8, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the visit (99214) provided on June 27, 2021.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the services were billed
incorrectly.
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 99214 is "Office or other outpatient visit for the
evaluation and management of an established patient, which requires a medically appropriate history and/or
examination and moderate level of medical decision making. When using time for code selection, 30-39
minutes of total time is spent on the date of the encounter".
We find that CPT code 99214 is not supported in the medical record. Specifically, the records show that the
visit was rendered in the emergency room. It is inappropriate to bill code 99214 for an emergency room visit.
Based on this information, we decided that Medicare rules for coverage of the visit have not been met.
Therefore, we decided that the Plan does not have to pay for the visit (99214) provided on June 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve tooth root removal (D7250).  You asked the Plan to pre-approve the dental services. You say that the enrollee has severe dental disease. You say that this can easily affect their overall health and in severe cases lead to infection. You also say that the services are medically necessary. The Plan denied your request. The Plan says the requested service is not covered by the Plan or Medicare.  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 services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Additionally, though the Plan offers a dental benefit in excess of Medicare coverage, the requested tooth root removal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve tooth root removal (D7250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on July 16, 2021.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.
We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM
and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate
Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered
on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a removal of residual tooth roots (D7250).  You asked the Plan to pre-approve the removal of residual tooth roots. You say that you need this procedure to be covered because you are in pain. The Plan denied your request. The Plan says this service is 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 pre-approve a removal of residual tooth roots (D7250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a removal of lateral exostosis (D7471) and two removals of torus mandibularis (D7473 x2).  You asked the Plan to pre-approve the removal of lateral exostosis and removals of torus mandibularis. The Plan denied your request. The Plan says these services are not covered under your benefit package.  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 pre-approve a removal of lateral exostosis (D7471) and two removals of torus mandibularis (D7473 x2).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing (81455) provided on July 26, 2021.  You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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 that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing (81455) provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) provided on October 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond crown. You say that you were advised that the facility you were treated at was in-network. The Plan denied your request. The Plan says the treating provider is OON, and the claim was paid correctly.  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 because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) provided on October 4, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 28, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-
network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says there are in-network providers available to render the
requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office
consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided to the enrollee on August 2, 2021.

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 the provider has not submitted any clinical records to support the medical necessity of these services.

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. Based on this information, we decided that Medicare rules for the services at issue have not been met. Specifically, the case file did not contain medical records for the billed services. Without the medical records, the billed services cannot be verified. Therefore, we decided that the Plan does not have to pay for pain management services provided to the enrollee on August 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the bone replacement graft for ridge preservation (D7953) provided on July 26, 2021.  You asked the Plan to pay more for the bone replacement graft. You say that after you had a tooth pulled and was checking with the desk about payment, the clerk advised you did not owe anything. You also say that you would like to appeal this service. The Plan denied your request. The Plan says you met your $1,000 annual dental allowance during the processing of this claim.  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 $1,000 annual dental benefit maximum. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the July 26, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the bone replacement graft for ridge preservation (D7953) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer screening, prostate specific antigen (PSA)
tests (G0103) provided September 17, 2021.
You asked the Plan to pay for the prostate cancer screening. You say that the PSA test on September 17, 2021
was ordered as a follow up screening ordered on August 17, 2021. The Plan denied your request. The Plan says
this service exceeds the maximum benefit frequency limitation.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The health Plan contract on page 4-58 of the 2021 Evidence of Coverage says that a Prostate specific Antigen
(PSA) test is covered once every 12 months. The records show that the Plan has already paid for this test for
date of service August 17, 2021. Therefore, we decided that the Plan does not have to pay for prostate cancer
screening, prostate specific antigen (PSA) tests (G0103) provided September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint (64625).  You asked the Plan to pre-approve RFA of the SI joint. You say that this is medically necessary for the enrollee's conditions as multiple randomized controlled trials have demonstrated the efficacy of the procedure. The Plan denied your request. The Plan says this procedure is considered experimental/investigational at this time.  The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary/investigational.  We looked at the file and Medicare rules. In this case, the requested procedure is considered not medically necessary/investigational according to Medicare Local Coverage Determination rules. Based on this information, we decided that Medicare rules for coverage of RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint (64625).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities provided on May 18, 2021.
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code to bill
for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that therapy services provided and billed incident to the services of a
physician/NPP also must meet all incident-to requirements in Section 60 of Chapter 15 of the
Benefit Policy Manual.
We find that CPT code 97530 is not supported in the record. Specifically, this claim was billed by a nurse
practitioner but the services were rendered by an occupational therapist. There is no evidence in the file that
incident-to criteria have been met as the documentation does not indicate that the nurse practitioner was present
on site when the services were rednered. Based on this information, we decided that Medicare rules for
coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to
pay for the therapeutic activities provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010), bone grafts at time of implant placements (D6104), and radiographic/surgical implant indexes (D6190).  You asked the Plan to pre-approve the endosteal implants, bone grafts, and radiographic/surgical implant indexes. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  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 pre-approve surgical placements of implant bodies: endosteal implants (D6010), bone grafts at time of implant placements (D6104), and radiographic/surgical implant indexes (D6190).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network
(OON) provider.

You asked the Plan to pre-approve a specialist office visit. You say that there was no specialist provider in-network
to provide the care. The Plan denied your request. The Plan says there are multiple in-network
providers that can provide the same specialty and a list was provided to the enrollee.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous passive motion (CPM) device (E0395), provided on March 29, 2021, through April 11, 2021.  You asked the Plan to pay for the CPM device. You say that the item was medically necessary. The Plan denied your request. The Plan says there is insufficient evidence that a total knee replacement surgery was performed.  The Plan must follow Medicare rules. The rules say that CPM devices are covered only if use of the device began within two days of receiving total knee replacement surgery.   Records do not show that total knee replacement surgery was performed, but the use of a CPM device began on March 29, 2021.        This means there is insufficient evidence that the use of a CPM device began within two days of a total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for the continuous passive motion (CPM) device (E0395), provided on March 29, 2021, through April 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the podiatry visits and pay for the shoe inserts provided pm June 1, 2021, through July 27, 2021.  You asked the Plan to waive the copayment for the podiatry visits and pay for the shoe inserts. You say that these services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly, and shoe inserts are not covered benefits.  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 $30 copay for podiatry services.   You have been asked to pay a $30 copay for the podiatry visits and pay for the shoe inserts. The podiatry visits fall within the Podiatry services 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. Orthopedic shoes and other supportive devices for the feet generally are not covered. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry visits and pay for the shoe inserts provided pm June 1, 2021, through July 27, 2021.