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

We decided that the Plan does not have to pay an additional amount for the 2D photographic images (D0350 x
4), panoramic x-ray (D0330), and the application of fluoride (D1208) provided on April 21, 2021.

You asked the Plan to pay an additional amount for the dental services. You say that you found a dentist on the
provider directory. You say that the provider you were scheduled to see was out on maternity leave which you
found out after the appointment. You also say that you cannot afford to pay for these services. The Plan denied
your request. The Plan says 2D photographic images and topical application of fluoride are not listed as
covered services. The Plan says that 1 panoramic or full mouth series x-ray is covered every 3 years. The Plan
also says that the frequency limit has been exceeded.

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 2D photographic images and
application of fluoride are not among those covered under this benefit. Although panoramic x-ray is listed as a
covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a complete
series x-ray that you received on this date of service. Therefore, we decided that the Plan does not have to pay
an additional amount for the 2D photographic images (D0350 x 4), panoramic x-ray (D0330), and the
application of fluoride (D1208) provided on April 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services and an x-ray provided on January 19, 2021
by an out-of-network (OON) provider.
You asked the Plan to pay for specialist services and an x-ray. You say that these services were medically
necessary. You say that you did not realize the member was part of this specific plan. The Plan denied your
request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan
says that there are in-network physicians available to provide these 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 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 specialist services and an x-ray provided on
January 19, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not meet the coverage criteria for
admission to an SNF. Admission to an SNF is not reasonable and not medically necessary as you have no
skilled nursing needs and do not need skilled therapies on a daily basis in an inpatient setting at your current
level of function and fatigue. You were medically stable after acute illness and now with severe debility with
no daily skilled nursing care needs. You will not tolerate daily therapies. Documentation does not support the
need for an admission to an SNF. Your rehabilitation needs can be met at a lower intensity level such as in a
long-term care (LTC) facility with intermittent therapies.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a Group 2 POV is denied as not medically necessary. 

We looked at the file and Medicare rules. The item at issue is a Group 2 POV described by procedure code K0806. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power operated vehicle (POV).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 3, 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 you 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 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 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 on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a breath hydrogen or methane test (91065) provided on April 21, 2021. You asked the Plan to pay for a breath hydrogen or methane test. You say that this is not included in the global surgical package. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that two modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure. We looked at the file and Medicare rules. The service at issue was provided during the 10 day global surgical period of a hemorrhoidectomy (46221) that was performed on April 13, 2021, but it was not billed with a modifier to indicate it was unrelated. Based on this information, we decided that Medicare rules for coverage of a breath hydrogen or methane test have not been met. Therefore, we decided that the Plan does not have to pay for a breath hydrogen or methane test (91065) provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home glucose monitor and supplies.

You asked the Plan to pre-approve a home glucose monitor (E0607) and supplies (A4259, A4253). You say that the enrollee needs a home glucose monitor and supplies. The Plan denied your request. The Plan says the enrollee has not been diagnosed with diabetes.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file and Medicare rules. The enrollee does not have diabetes. Based on this information, we decided that Medicare rules for coverage of a home glucose monitor (E0607) and supplies (A4259, A4253) have not been met. Therefore, we decided that the Plan does not have to pre-approve a home glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010) for the enrollee.

You asked the Plan to pre-approve the sleeve. You say that this is medically necessary. The Plan denied your request. The Plan says this cannot be approved.

The Plan must follow Medicare rules. The rules say that a mastectomy sleeve (L8010) is denied as noncovered, since it does not meet the definition of a prosthesis. 

The requested sleeve is statutorily non-covered by Medicare. Additionally, a mastectomy would not be covered without a personal history of mastectomy. This is not evident in the records. Based on this information, we decided that Medicare rules for coverage of the sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6539 that were issued on March 12, 2021 and April 9, 2021.

You asked the Plan to pay for the compression stockings. You say that you were told compression stockings were covered. The Plan denied your request. The Plan says these compression stockings are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6539 that were issued on March 12, 2021 and April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110), complete
mandibular denture (D5120), and adjunctive procedure (D9999) provided on April 20, 2021 by a Medicare opt
out provider.

You asked the Plan to pay for the complete maxillary denture, complete mandibular denture, and adjunctive
procedure. You say that the provider said they accepted your insurance. You also say that you were not advised
that this provider did not accept Medicare. The Plan denied your request. The Plan says the treating provider
opted out of Medicare effective September 21, 2015, to September 21, 2021. The Plan also says that charges
incurred by a Medicare opt out provider will not be reimbursed.

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
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the complete maxillary denture (D5110), complete mandibular denture (D5120),
and adjunctive procedure (D9999) provided on April 20, 2021 by a Medicare opt out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581,
87631, 87640, 87798) provided on September 4, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported by the records. The Plan
denied your request. The Plan says this was billed with an incorrect POS. The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87541, 87581, 87631, 87640,
87798) provided on September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit (99285) provided on June 3, 2020.

You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service was not billed with the required anatomical modifier.

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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. 

We find that CPT code 99285 is supported in the record. Specifically, this service was billed correctly without an anatomical modifier. It would not be appropriate to append an anatomical modifier to the emergency department visit code. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have been met. Therefore, we decided that the Plan has to pay for the emergency department visit (99285) provided on June 3, 2020.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on June 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a colonoscopy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there is no referring provider listed.

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 colonoscopy provided on June 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Radiofrequency Ablation (RFA) procedure (64636, 64635).

You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says repeat diagnostic procedures are required before this service can be considered.

The Plan follows Medicare rules. Medicare rules say that if there is an extended period of time, two years or more, since the last RFA, and/or there is a question as to the source of the recurrent pain, then diagnostic procedures must be repeated. 

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 ablation procedure. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the record indicates that the enrollee previously had radiofrequency ablation at the L3-L4, L4-L5, and L5-S1 levels in May 2019. The record indicates that the enrollee had 85% improvement for over a year. The radiculopathy has been treated with a spinal cord stimulator. The record does not indicate that the enrollee has had repeat diagnostic procedures. The elements of the coverage criteria are not satisfied. 

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 ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Radiofrequency Ablation (RFA) procedure (64636, 64635).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81402, 81403, 81404) provided on
March 20, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this is covered by Medicare. The Plan denied
your request. The Plan says this is not supported in the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also state that code 81479 is used to
report Guardant360 testing. We find that CPT codes 81402, 81403, and 81404 are not supported in the medical record. Specifically, these codes were used to report Guardant360 testing, which should be billed with 81479. Based on this information,
we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided
that the Plan does not have to pay for Guardant360 testing (81402, 81403, 81404) provided on March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the amalgam (D2140) and root canal (D3330) provided on December 29, 2020.
You asked the Plan to pay an additional amount for the dental services. You say that you were advised by a plan representative that the root canal would be covered at 50%. You say that you were never told that the maximum amount that would be paid was $252 until after you received payment. You also say that the services should be paid at 50% of the charged amount. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that providers are paid based on a Maximum Allowable Charge (MAC). The Plan also says that out of network providers may bill you for any amount greater than the MAC payment made.
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 services are listed as covered, out of network providers may bill you for any amount greater than the MAC payment. Additionally, the record shows that the plan representative advised that out of network providers may bill you for any amount greater than the MAC. Therefore, we decided that the Plan does not have to pay an additional amount for the amalgam (D2140) and root canal (D3330) provided on December 29, 2020.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pay for the hospital discharge day management service (99239) provided on
January 25, 2021.

You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says that the billed
diagnosis falls under excluded services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99239 is supported in the medical record. Specifically, the record indicates that the
member was in an inpatient hospital stay. The inpatient admission and members conditions including facial
cellulitis and pre-renal azotemia, show that these services were medical in nature. Based on this information,
we decided that Medicare rules for coverage of the hospital discharge day management services have been met.
Therefore, we decided that the Plan has to pay for the hospital discharge day management service (99239)
provided on January 25, 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 an injection provided on May 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an injection. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is also out-of-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 injection provided on May 21, 2021 by an out-of-network (OON) provider