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

We decided that the Plan does not have to pre-approve a lower jaw bone graft (21215) and dental implant/reconstruction of the jaw (21248) to be approved under the medical benefit.

You asked the Plan to pre-approve the bone graft and reconstruction of jaw. You say that these services are necessary, as the enrollee was left with a large gap between two teeth following previous reconstruction that resulted from an automobile accident in 2018. The Plan denied your request. The Plan says the enrollee received the medically necessary services following the accident. The additional services requested at this time are purely dental in nature. They are unrelated to the limited clinical indications and are not eligible for coverage under the medical benefits.

Medicare generally does not cover dental services. Medicare can consider coverage of some facial and maxillofacial procedures if the services are found to be medically necessary in relation to certain listed diagnoses relating to the repair of injuries due to trauma or ablative surgery.

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. The accident referenced in this case occurred three years prior, and documentation shows that the enrollee already had care provided in relation to this trauma. The diagnoses provided for review are also not among those listed as medically necessary indications for reconstructive surgeries of the head and neck to repair injuries due to trauma or ablative surgery. The Plan does offer a limited supplemental dental benefit which may be able to cover some treatment options, but it does not cover the services at issue as requested. Therefore, we decided that the Plan does not have to pre-approve a lower jaw bone graft (21215) and dental implant/reconstruction of the jaw (21248) to be approved under the medical benefit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.

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 drug testing provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for a home evaluation and management (E&M) visit provided on August 2,
2021.
You asked the Plan to pay for home visit. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says that the denial of payment for this service is correct, because this provider is
out-of-network with the Plan and a referral was not obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that plans can require enrollees to get care from network providers. The enrollee's
contract with the Plan says that the Plan has a Point of Service (POS) option that allows enrollees to receive
service from out-of-network providers without a referral.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan denied payment for this service because the provider is out-of-network
with the Plan and no referral or authorization was obtained. However, this Plan's POS benefit allows the
enrollee to obtain covered services from out-of-network providers without need for a referral. The enrollee's
contract with the Plan does not clearly state that prior authorization is required for coverage of a
physician/practitioner services such as a home E&M visit. The Plan did not provide any other rationale or
evidence to support denial of payment for this service. Therefore, the Plan has not shown that its decision to
deny payment for this service is correct or justified according to Medicare rules or the enrollee's contract with
the Plan. Therefore, we decided that the Plan has to pay for a home evaluation and management (E&M) visit
provided on August 2, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided by a
participating provider on August 23, 2021.
You asked the Plan to pay for an unspecified preventive procedure. You say that you would like the Plan to pay
for this. The Plan denied your request. The Plan says the dental services that were provided are not a covered
benefit.
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 an
unspecified preventive procedure (D1999) provided by a participating provider on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose monitor (K0553) provided on July 21, 2021.

You asked the Plan to pay for a supply allowance for a continuous glucose monitor. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for therapeutic continuous glucose monitors and related supplies have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a supply allowance for a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for a supply allowance for a therapeutic continuous glucose monitor (K0553) provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for intraoral radiographic imaging (D0220 and D0230), provided by a participating provider on August 31, 2021.

You asked the Plan to pay for intraoral radiographic imaging. You say that you should have unlimited imaging for this. The Plan denied your request. The Plan says that these images are not a covered benefit.

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 Plan covers intraoral radiographic imaging when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of intraoral radiographic imaging have been met. Therefore, we decided that the Plan has to pay for intraoral radiographic imaging (D0220 and D0230), provided by a participating provider on August 31, 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 out of network physician services provided to the enrollee on June 17, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on December 23, 2020.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 genetic testing 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 genetic testing provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services provided from May 27, 2020, to August 24, 2020.
You asked the Plan to pre-approve dental services. You say that you saw this provider as an emergency and they never advised you that they were out-of-network. The Plan denied your request. The Plan says the denial of payment for these services is correct, because dental services are not covered when performed by an out-of-network provider.
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 dental services provided from May 27, 2020, to August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided from June 11, 2021, through August 6, 2021.

You asked the Plan to pay for ophthalmology services. The Plan denied your request. The Plan says the services were provided by an out-of-network 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 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 ophthalmology services provided from June 11, 2021, through August 6, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenomic testing provided on April 19, 2021 billed with codes 81479, 81227, 81230, 81240, 81241, 81291, 81335, and 81355.

You asked the Plan to pay for the pharmacogenomics testing. You say that this is medically necessary. The Plan denied your request. The Plan says that only one unit of service must be reported for a multigene panel. However, it was decided that five of the genes should be paid individually.

The rules cited by the Plan do not support that individual genes cannot be billed. The fact that the Plan elected to pay five of these codes also refutes this interpretation of the rule.

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. 

The enrollee was referred for the pharmacogenomics testing by a contract provider. The file does not show that the plan provided notice that the pharmacogenomics testing would not be covered. Under Medicare rules, this means the pharmacogenomics testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the pharmacogenomic testing provided on April 19, 2021 billed with codes 81479, 81227, 81230, 81240, 81241, 81291, 81335, and 81355.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 17, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your request. The Plan says you refused transport to the hospital. The Plan also says that Medicare does not provide payment for ambulance response and treatment if there is no transport.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on June 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye examination provided on June 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for eye exam. You say that you looked for a second opinion on your own due to your dissatisfaction with the in-network provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is not participating in the Plan's vision network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan 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 an eye examination provided on June 13, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the requested inpatient admission is
medically necessary. The Plan denied your request. The Plan says the requested inpatient admission does not
meet criteria.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee is scheduled for a reverse shoulder arthroplasty. The record does not
state a medical reason why the enrollee will require inpatient admission. The enrollee may be admitted for
observation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the four non-emergency ambulance transports (A0428 x4) and ground mileage (A0425 x4) provided on January 8, 2021, and February 19, 2021.
You asked the Plan to pay for the ambulance transports and mileage. You say that the ambulance service for transportation was medically necessary. The Plan denied your request. The Plan says there was no documentation that the ambulance was medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 the ambulance transports and mileage. Our reviewer says that the documentation does not support that the ambulance transports were medically reasonable and necessary for you. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van) were contraindicated for you on January 8, 2021, and February 19, 2021. Our reviewer also found that the documentation does not support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on January 8, 2021, and February 19, 2021.
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 ambulance transports and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the four non-emergency ambulance transports (A0428 x4) and ground mileage (A0425 x4) provided on January 8, 2021, and February 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgery provided on August 16, 2021.
You asked the Plan to waive the deductible for the outpatient surgery. You say that you do not understand why you have to pay all this money for a surgical procedure that was done on suspicious moles on your back. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to the outpatient surgery. The outpatient surgery you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to the outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery was received on August 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgery provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided from April 9, 2021, to April 13, 2021.

You asked the Plan to pay for the services provided. You say that denying coverage based on a diagnosis code is a violation. The Plan denied your request. The Plan says the documentation does not support the level of care.

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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient. Usually, the patient is unstable or has developed a significant complication or a significant new problem.

We find that CPT code 99233 is not supported in the medical record. The file shows that the enrollee was seen for right lower extremity swelling. The records do not indicate the enrollee was unstable, experienced a significant complication, or developed a significant new problem. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided from April 9, 2021, to April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on June 2, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan and
have been before. The Plan denied your request. The Plan says this provider has opted out of the Medicare
program. The Plan states any payment to this provider previously were done so in error.
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. The
services at issue in this appeal were rendered by a provider who has opted out of the Medicare program.
Therefore, we decided that the Plan does not have to pay for physician services provided on June 2, 2021.