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

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on March 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider, and we did not know that the facility failed to get preauthorization for this patient, so we treated this patient anyway. The Plan denied your request. The Plan says this provider is out-of-network with the Plan and authorization was not obtained prior to the services being rendered.

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 a domiciliary or rest home visit (99336) provided on March 17, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 11, 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 was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on April 13, 2021.
You asked the Plan to pay for the crown. You say that you contacted the Plan and were advised the crown
would be covered at 50%. The Plan denied your request. The Plan says this service is not a covered benefit
under your dental 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 crown
(D2740) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve.  You asked the Plan to pre-approve the requested services. You say that the procedure improves the quality of life for those suffering from low back pain. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.  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 requested services. Our physician reviewer found that the enrollee has chronic low back pain due to degenerative disc disease. He has tried activity modification, physical therapy, lumbar injections, massage therapy, and medication management. The requested procedure targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. Published studies do not demonstrate any long-term health outcome advantage with the use of this procedure as an alternative to standard surgical treatment. The review has determined that the requested procedure is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve the intraosseous ablation of the basivertebral nerve.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on September 16, 2021.  You asked the Plan to pay for code 70450. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a seat lift mechanism.  You asked the Plan to pre-approve a seat lift mechanism. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a seat lift mechanism. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not show that the enrollee is completely incapable of standing from a chair in the home.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a manual wheelchair provided on September 7, 2021.  You asked the Plan to waive the coinsurance for a manual wheelchair. You say that the wheelchair was coronavirus (COVID-19) related and the enrollee should not have any out-of-pocket expenses. The Plan denied your request. The Plan says the coinsurance applied was right.  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% coinsurance for Out-of-Network Medicare-covered items. The total amount allowed for the manual wheelchair was $3,278.97 with a coinsurance of $983.69 ($3,278.97 total amount x 30% coinsurance). The plan stated the enrollee was charged an In-Network coinsurance of 20%. With the total amount allowed of $3,278.97 and a coinsurance of $655.80 ($3,278.97 total amount x 20%). You have been asked to pay a 20% coinsurance for a manual wheelchair. A manual wheelchair falls within the Durable medical equipment (DME) and related 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 coinsurance for a manual wheelchair provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on July 26, 2021.  You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99152.  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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of   the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.  We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not contain evidence that moderate sedation was performed with the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiofrequency ablation (64625) surgical service provided on June 25, 2021.

You asked the Plan to waive the copayment for the radiofrequency ablation. You say that the services should be covered as your previous injections have been covered. The Plan denied your request. The Plan says the cost-sharing applied for surgical services, not injections. The cost-sharing applied correctly.

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 $125 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $125 copayment for a radiofrequency ablation. The record indicates that these services were performed in an outpatient setting. Radiofrequency ablations fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the radiofrequency ablation (64625) surgical service provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Radiologic examination (74019) provided on September 17, 2021.  You asked the Plan to pay for code 74019. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74019 is a column II code to column I code 74270. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Radiologic examination (74019) provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on February 12, 2021.  You asked the Plan to pay for the services provided. You say that the tests were billed as ordered by the physician. The Plan denied your request. The Plan says the code remains not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records provided do not indicate that the specimen was obtained at the independent laboratory. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on February 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the developmental/behavioral screening and testing; psychotherapy and interactive complexity provided from August 18, 2021, through September 16, 2021, an out-of-network provider.  You asked the Plan to pay for the services. You say that all of your claims have denied for the provider is not approved to bill Medicare. The Plan denied your request. The Plan says the enrollee's doctor did not send notes that show why the enrollee needed to use an out-of-network provider. The Plan states the enrollee underwent therapy with a person who was not contracted with Medicare and this therapy with this provider is not medically necessary.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the developmental/behavioral screening and testing; psychotherapy and interactive complexity provided from August 18, 2021, through September 16, 2021, an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power scooter.  You asked the Plan to pre-approve the power scooter. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  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.   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 power scooter. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation indicating your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair or that you can safely operate a PMD. Also, it is unknown if your home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the requested POV.   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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve the power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the domiciliary or rest home visit (99334) provided on April 28, 2021.   You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $40 copayment for each Medicare-covered specialist visit.   You have been asked to pay a $40 copayment for the Medicare-covered specialist visit provided. 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 the domiciliary or rest home visit (99334) provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on June 23, 2021.  

You asked the Plan to pay for the hearing aids. You say that you feel these hearing aids should be covered in full and you do not understand why they are denied. The Plan denied your request. The Plan says the hearing aids purchased on June 23, 2021, are not among those listed as covered under your hearing benefit.  

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only if they are among those listed as covered in the contract and purchased from a provider in the Plan's specified routine hearing network.    

We looked at the file and the Plan's rules. The hearing aids purchased on the date in question are not among those listed as covered in the Plan's contract. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical extractions (D7210) for teeth # 21, 22, 23, 24, 25, 26, 27, 28, and 29.  You asked the Plan to pre-approve the surgical extractions. You say that the extractions are necessary. The Plan denied your request. The Plan says surgical extractions are not medically necessary.  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 the surgical extractions when the services are medically necessary and reasonable.   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 surgical extractions. Our reviewer says that the requested surgical extractions do not meet the criteria for coverage. Our physician reviewer found the teeth have intact clinical crowns and some bone loss noted making removal easier and without any anticipation of the need for removal of bone. The reviewer found that the Plan criteria has not been met for surgical extractions under code D7210.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical extractions have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) for teeth # 21, 22, 23, 24, 25, 26, 27, 28, and 29.