Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture to treat knee pain.
You asked the Plan to pre-approve the services. You say that you want to avoid knee replacement surgery. The Plan denied your request. The Plan says this is only covered to treat chronic low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. Acupuncture is not covered for treatment of knee pain. 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 acupuncture to treat knee pain
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional outpatient physical therapy (PT) visit.
You asked the Plan to pre-approve the additional PT visits. You say that it is felt that ongoing PT would be of benefit to the enrollee. The Plan denied your request. The Plan says ongoing PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The
patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has improved her balance and mobility. She is performing a home exercise program. She does not require ongoing skilled PT. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional outpatient physical therapy (PT) visit
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a therapy procedure using a positive pressure ventilator provided on April 27, 2021.

You asked the Plan to waive the copayment for a therapy procedure using a positive pressure ventilator. You say that you are being charged a copayment for services you did not receive. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $50 copayment for each outpatient diagnostic procedure and test provided in an office setting.

The medical records show that you received a therapy procedure using a positive pressure ventilator on April 27, 2021. Therefore, you are responsible to pay the $50 copayment. 

You have been asked to pay a $50 copayment for a therapy procedure using a positive pressure ventilator. A therapy procedure using a positive pressure ventilator falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a therapy procedure using a positive pressure ventilator provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a wellness visit received on September 23, 2020.
You asked the Plan to pay for the visit. You say that this was a required physical to clear you for surgery. The Plan denied your request. The Plan says the annual wellness visit can only be performed once every calendar year.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for a wellness visit received on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2750, V2020, V2784, V2702, V2781) provided on October 7, 2021.
You asked the Plan to pay for the eyeglasses. You say that you were not told that lens upgrades were not covered, and you feel the Plan should pay for these services. The Plan denied your request. The Plan says the total billed cost of the eyeglasses was $254. The Plan paid the full $200 annual allowance for the eyeglasses, and you are responsible for the remaining cost.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays up to $200 for eyeglasses or contacts every year. After plan paid benefits for eyeglasses or contact lenses, you are responsible for the remaining cost. We looked at the file and the Plan's rules. Documentation shows that the full cost of the glasses purchased on October 7, 2021, was $254. The Plan has paid $200, and you are responsible for the remaining $54. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2750, V2020, V2784, V2702, V2781) provided on October 7, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft (20900) provided on March 12, 2021.
You asked the Plan to pay for the bone graft (20900). You say that the medical records and reconsideration request should be reviewed. The Plan denied your request. The Plan says CPT code 20900 s not supported in the documentation therefore is not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 20900 is bone graft, any donor area; minor or small (eg, dowel or button).
We asked our coder 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 bone graft (20900). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not include documentation of a separate incision for bone grafting. The bone graft codes CPT 20900 and CPT 20902 are separately reportable only when the graft material is an autograft and is obtained through a separate incision and not listed as part of the basic procedure. In this case, CPT 20900 would not be separately reported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone graft (20900) have not been met. Therefore, we decided that the Plan does not have to pay for the bone graft (20900) provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on July 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you were not aware you needed authorization. The Plan denied your request. The Plan says the enrollee was not referred by an in-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 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 (G0483, 80307) provided on July 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for telehealth visits provided from September 3, 2021, to September 24, 2021.

You asked the Plan to waive the deductible for telehealth visits. You say that you should only owe a $35 copayment and disagree with the higher charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $750 deductible which applies to telehealth services. 

You received telehealth visits on September 3, 2021, and September 24, 2021. The record shows that you had not met the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $150. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category telehealth services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to telehealth services. This cost sharing is a contractual obligation that had not been met at the time telehealth visits were received on September 3, 2021 to September 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for telehealth visits provided from September 3, 2021, to September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial mandibular denture (D5212) to be provided by a participating provider.

You asked the Plan to pre-approve a partial mandibular denture. You say that you would like the Plan to approve and pay for this partial denture. The Plan denied your request. The Plan says the requested dental service is 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 pre-approve a partial mandibular denture (D5212) to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and supplies for the enrollee.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan denied your request. The Plan says that the member injects insulin twice a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and supplies for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 10, 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 this testing is considered unproven and 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 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical value of PCR testing in the setting of urinary tract infections is not the standard of care and remains unproven in the peer-reviewed medical literature. The review has determined that the services at issue in this case were not medically reasonable or necessary.

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 pay for laboratory services provided to the enrollee on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on January 15, 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 separately payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. 

We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).

You asked the Plan to pre-approve the dental item. You say that this is an emergency. You say that you cannot chew. You also say that you are in excruciating pain. The Plan denied your request. The Plan says partial upper denture is covered once every 60 months. The Plan also says that the frequency limit has been reached.

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 and the requested partial denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on January 16, 2018. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97163) provided on September 16, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the physical therapy. You say that your primary care provider referred you for these services, and they should be covered. Your provider should have sent the documentation. The Plan denied your request. The Plan says no referral for these services with this provider was received by the Plan. These services were rendered by an out-of-network provider. Out-of-network care is only covered in certain limited circumstances. No referral was submitted, the services were not urgent or emergent, and there were in-network providers available for this care.

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, and no referral was submitted for review. 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 physical therapy services (97163) provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 27, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you were not happy with your previous dentist who provided a similar exam. You also say that you had another exam with a new dentist. The Plan denied your request. The Plan says this procedure exceeds the frequency limitations under your 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, comprehensive oral exam (D0150) is covered once every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on March 6, 2020 and your comprehensive oral exam (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 27, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 25, 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 authorization must be requested 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 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 services provided to the enrollee on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two gingival irrigations (D4921 x2) and drugs or medicaments dispensed in the office for home use (D9630) provided on August 27, 2021.

You asked the Plan to pay for the gingival irrigations and drugs or medicaments. You say that the dental office you were treated by is listed as in-network. The Plan denied your request. The Plan says these services are not covered benefits under your 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 pay for the two gingival irrigations (D4921 x2) and drugs or medicaments dispensed in the office for home use (D9630) provided on August 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted therapeutic procedure (97139) provided by an acupuncturist on April 12, 2021.

You asked the Plan to pay for the unlisted therapeutic procedure (97139). The Plan denied your request. The Plan says acupuncture and related services are not covered benefit by Medicare, except for chronic low back pain.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the unlisted therapeutic procedure have not been met. Specifically, the enrollee does not have a diagnosis of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the unlisted therapeutic procedure (97139) provided by an acupuncturist on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional computed tomography scan of the abdomen and pelvis (74177) provided on July 21, 2021.

You asked the Plan to pay for an additional computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this was previously paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that an additional unit of CPT code 74177 is not supported in the medical record. The medical record only supports 1 unit of CPT code 74177, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of an additional computed tomography scan have not been met. Therefore, we decided that the Plan does not have to pay for an additional computed tomography scan of the abdomen and pelvis (74177) provided on July 21, 2021.