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

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and surgical extraction (D7210) provided on April 9, 2021. You asked the Plan to pay for the exam and extraction. You say that you went to have this tooth extracted by your in-network dentist, but during the extraction the tooth broke, and you needed to see another provider for a surgical removal. You provided a referral from your dentist to the out-of-network provider for review. The Plan denied your request. The Plan says that the limited oral evaluation is not a covered service under your dental benefit. In addition, services must be provided by a participating general dentist in order to be eligible for coverage.  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. Problem-focused exams (D0140) are not a covered service under your dental benefit. Services must be performed by a participating general dentist.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested limited oral exam is not among those covered under this benefit, regardless of who provides the service. In addition, services must be performed by a general dentist. While there is a referral provided in this case, the contract is clear that services performed by dental specialists other than a general dentist will not be covered. The provider in this case is a periodontist and not a general dentist. If a service is never covered by the Plan and the Plan's Evidence of Coverage is clear that the service or item is never covered, the Plan does not have to hold the enrollee harmless. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and surgical extraction (D7210) provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve esophagogastroduodenoscopy (EsophyX Transoral Incisionless Fundoplication).  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a hiatal hernia that is more than 2 cm.  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 there is no provided documentation of proton pump inhibitor (PPI) refractory advanced esophagitis, of lack of response nor intolerance to acid suppression therapy, of symptoms correlative with acid reflux events, nor was manometry data presented to objectively show that the enrollee's lower esophageal sphincter presently requires re-augmentation by surgical re-intervention. As such, the medical necessity of the TIF procedure is not apparent based on the enrollee's available records, especially given the substantial complication and failure rates of the requested procedure and the enrollee's unique circumstance.  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 esophagogastroduodenoscopy (EsophyX Transoral Incisionless Fundoplication).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for a surgical tooth extraction (D7210) provided on January 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to provide additional reimbursement for a tooth extraction. You say that your tooth was surgically extracted, and you have submitted your medical chart notes. You also say this claim needs to be paid. The Plan denied your request. The Plan says the enrollee is responsible for the difference between the INFS and dentists' charged fees when visiting an OON provider. The Plan also says neither the enrollee nor provider contacted 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. 

We looked at the file and Medicare rules. The records show you received services from an OON provider. The EOC confirms if an enrollee sees an OON provider, the coinsurance level will apply to the average negotiated INFS. Based on this information, we decided that the Plan's rules for coverage of a tooth extraction have not been met. Therefore, we decided that the Plan does not have to provide additional reimbursement for a surgical tooth extraction (D7210) provided on January 6, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transport components for your authorized wheelchair (K0108).  You asked the Plan to pre-approve transport components. You say that the transit belt is necessary to secure the chair in the car. The Plan denied your request. The Plan says LCD are clear that no accessories can be approved for "recreational or leisure use", that is, use 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 item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve transport components for your authorized wheelchair (K0108).
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. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are currently unstable for transfer to an LTACH.  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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear more stable and improving but only require short-term additional acute care services that can be safely administered at the current facility until lower level of care services are more appropriate. You do not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.    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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a safe step walk in bath rub provided on April 30, 2021 by a nonparticipating provider.  You asked the Plan to pay for the safe step walk in. You say that you have arthritis and the walk in tub should be covered. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of 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 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 a safe step walk in bath rub provided on April 30, 2021 by a nonparticipating provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) services after November 11, 2021.  You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because the continued SNF care is medically necessary. The Plan denied your request. The Plan says you do not have any daily skilled care needs.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish a safe and effective maintenance program.  As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care.  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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) services after November 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on March 26, 2021.  You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says 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 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 pay for ambulance service, basic life support, emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is an 86-year-old female with low back and neck pain who was transported via ambulance. The enrollee was hemodynamically stable and transported without issue via stretcher. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The enrollee's vitals were stable, and no acute condition required special care or supervision. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two resin-based composites (D2332 x2) provided on July 7, 2021.

You asked the Plan to pay for the resin-based composites. You say that you would like the Plan to pay for the complete series of intraoral x-rays. The Plan denied your request. The Plan says this service is not covered by your dental plan. The Plan also says that you signed a financial agreement with the provider's office for these 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, the requested items or services are not among those covered under this benefit. The record shows that you signed a financial agreement with the provider acknowledging that you would be fully responsible for the charges for the resin-based composites. Therefore, we decided that the Plan does not have to pay for the two resin-based composites (D2332 x2) provided on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgery services provided on January 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provided is not payable for these services.

The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. 

In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.

Therefore, we decided that the Plan does not have to pay for the assistant surgery services provided on January 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on October 30, 2020.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on October 21, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2020.  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 were not billed correctly.    The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided by an opted-out physician on July 19, 2021.

You asked the Plan to pay for office visit. You say that to your knowledge, this doctor has always been part of the Plan's network. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider has opted out of Medicare and is not payable.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit provided by an opted-out physician on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs (11402, 11403, 11404) provided June 9, 2021.

You asked the Plan to pay for the surgical services. You say that the decision to request the services of an assistant at surgery remains the responsibility of the primary surgeon. The Plan denied your request. The Plan says the billed codes 11404, 11403 and 11402 have a status indicator of 1 for assistant surgeons. A status indicator of 1 is a statutory payment restriction for assistants at surgery and therefore may not be paid.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 11404, 11404 and 11402. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs (11402, 11403, 11404) provided June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services (56632) provided on February 15, 2021, and February 16, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is an inpatient only procedure.

The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. 

The service at issue in this appeal was billed with CPT code 56632. This code is listed with a status indicator of "C" on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the surgery services (56632) provided on February 15, 2021, and February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power scooter.  You asked the Plan to pre-approve the power scooter. You say that the enrollee needs a power scooter for medium to long distances. The Plan denied your request. The Plan says the enrollee is able to ambulate and use a manual wheelchair.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on July 7, 2021.

You asked the Plan to pay for the dental services. You say that the care you received was only a simple evaluation. You also say that this is part of preventive care. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either.

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 limited oral evaluation and periapical x-ray are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on July 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services billed on August 18, 2020.  You asked the Plan to pay for the physical therapy services. You say that the contract and documents should be reviewed, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says the records do not support the code 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 medical records show a home visit was provided. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services billed on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an advanced prosthetic foot and multi-axial rotation.  You asked the Plan to pre-approve the foot prosthesis. You say that the enrollee needs a new foot for his prosthetic, his is not functioning correctly. The Plan denied your request. The Plan says Medicare does not cover replacements for items that are still under warranty.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.   The file shows that you have a prosthetic foot that is still under warranty and can be repaired. This would serve the same purpose as a new foot prosthesis. Therefore, we decided that the Plan does not have to pre-approve an advanced prosthetic foot and multi-axial rotation.