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

We decided that the Plan does not have to pay for the anesthesia services coded as 99140 and 99100 provided on March 16, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like these services reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment is made per Medicare rules for these services as coded.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). The CPT Code Manual definition of code 99140 is anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure). We find that CPT codes 99140 and 99100 are not eligible for payment according to Medicare rules. Specifically, CPT code 99100 and 99140 have a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT codes 99140 and 99100. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99140 and 99100 provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care and eye injections (67028, J9035, 92014, 92202, 92134) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve eye injections. You say that the services should be covered as you have been seeing this provider for the last nine years and would like to continue. The Plan denied your request. The Plan says these services can be provided in-network with providers who have the same qualifications.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The provider at issue in this case is not a network provider with the Plan. 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 eye injections. Our reviewer says that the requested physician is not a network provider, and the services can be safely rendered in-network.

Our physician reviewer found that the Avastin injections for the enrollee's neovascular age-related macular degeneration are medically reasonable and necessary but there is nothing in the available medical records to indicate that an in-network provider cannot provide equivalent level of care as the requested physician. Based on the medical records provided there is no documentation that an in-network provider cannot provide adequate care for the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eye injections have not been met. 

The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve eye injections. Therefore, we decided that the Plan does not have to pre-approve continued care and eye injections (67028, J9035, 92014, 92202, 92134) to be provided 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 periodontal maintenance (D4910) provided on September 22, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that on your previous plan you were allowed two prophylaxes and two periodontal maintenances per year, and you were not aware that the Plan had changed. You also say that you were just trying to be proactive about your dental health. The Plan denied your request. The Plan says this service is not covered.
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 periodontal maintenance (D4910) provided on September 22, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services 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 is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an ophthalmology office visit. You say that your requested provider informed you that your insurance will not pay. You say you asked the Plan to separate your Medicare benefits from the insurance plan. The Plan denied your request. The Plan says the request does not meet criteria for coverage. The Plan further states no information was provided to indicate the services are for emergency care. The Plan says the requested services are available within the Plan's 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an ophthalmology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extensive arthroscopic debridement (29823) provided on March 4, 2021.

You asked the Plan to pay for extensive arthroscopic debridement. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.

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 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).

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 extensive arthroscopic debridement. Our reviewer says that this code is not supported. Our reviewer found the operative report does not include enough documentation to confirm extensive debridement was performed. The operative report describes debridement in Labrum, Supraspinatus, Rotator cuff, Bursa, and "further debridement." The submitted documentation does not describe depth and how extensive of debridement performed, as well as debridement in anterior and posterior compartments. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extensive arthroscopic debridement have not been met. Therefore, we decided that the Plan does not have to pay for extensive arthroscopic debridement (29823) provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. You say that you received chiropractic services in the past that helped immensely. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 chiropractic services Our reviewer says that the documentation does not support that the requested chiropractic services are medically reasonable or necessary. Our physician reviewer found you have polyarthropathy. The provided medical records indicate that the chiropractic referral is for treatment of the knee and hip. The only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation if the subluxation has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. The elements of the coverage criteria are not satisfied. Therefore, you do not meet criteria for the requested 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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).

You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. The Plan denied your request. The Plan says the maxillary partial denture (D5213) exceeds the benefit allowance. The Plan also says that the mandibular partial denture (D5214) is only covered if there are less than 8 posterior teeth in occlusion, and the x-rays show that you have eight or more teeth that touch.

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 maxillary partial denture and mandibular partial denture 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 mandibular partial denture. Our reviewer says that the criteria for coverage of a mandibular partial denture (D5214) have not been met. Our physician reviewer found the lower arch is missing tooth #'s 17, 18, 31, and 32. The dental claim form noted that tooth #'s 19 and 30 were to be replaced as well, though extractions were not noted on the claim form. Our reviewer found that with the upper partial in place, there would be occlusal contacts on tooth #'s 4 and 29, 5 and 28, 12 and 21, and 13 and 20. Tooth #25 is missing, so there would be one missing tooth in the anterior region. Our physician reviewer also found that in this case, with eight posterior contacts present and one missing lower anterior tooth, the Plan criteria for a lower partial denture has not been met as there are sufficient posterior and contacts the Plan would require there be two missing lower anterior teeth in order to qualify. 

We looked at this physician's review, the file, and Medicare rules. The contract says that maxillary partial denture (D5213) is limited to once per 60 months. The record shows that you received a maxillary partial denture (D5213) on September 9, 2019 and your maxillary partial denture (D5213) benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the maxillary partial denture and mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that the enrollee reports lower back pain and tingling numbness with radiculopathy in the bilateral lower extremity. The Plan denied your request. The Plan says the available records indicate radiating pain to the lower extremities.

The Plan must follow Medicare rules. Medicare rules say that facet joint injections are only covered in the absence of untreated radiculopathy.

It is noted in this case that the enrollee reports radiculopathy in the bilateral lower extremity. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on August 11, 2021.
You asked the Plan to waive the copayment for a breast biopsy. You say that the biopsy was performed with other tests that you did not have to pay for. The Plan denied your request. The Plan says the biopsy was performed in an operating room and is more involved than other testing you received.
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 $150 copayment for outpatient surgery provided in an outpatient hospital facility setting.
You have been asked to pay a $150 copayment for a breast biopsy performed in an outpatient hospital facility setting. A breast biopsy falls 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 a breast biopsy provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external catheter from Purewick.

You asked the Plan to pre-approve external catheter from Purewick. You say that this item would help control the nighttime flow of urine. The Plan denied your request. The Plan says the requested items are 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 pre-approve external catheter from Purewick. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have urinary incontinence. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested item. Therefore, you do not meet criteria for the requested item. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of external catheter from Purewick have not been met. Therefore, we decided that the Plan does not have to pre-approve external catheter from Purewick.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty.
You asked the Plan to pre-approve blepharoplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that blepharoplasty is only covered for certain indications. 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 blepharoplasty. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have dermatochalasis. The visual field for the left eye tape is incomplete. The record indicates a field of 35% on the right. The record does not report a MDR1. Therefore, you do not meet criteria for the requested 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 blepharoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve blepharoplasty.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on January 3, 2021.
You asked the Plan to pay for the fixed wing air transport and mileage. You say that this transport was a medical emergency. The Plan denied your request. The Plan says that Medicare only covers air transport to a hospital.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 fixed wing air transport and mileage. Our reviewer says that the fixed wing air transport was medically reasonable and necessary. Our physician reviewer found the documentation does support that the patient suffers from an illness or injury that contraindicates transportation by any means other than ambulance. She required bilevel positive airway pressure and was sent to the medical intensive care unit. Our reviewer found that the documentation does support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. The patient required quick transport to the other hospital. Our physician reviewer also found that the documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. The transferring hospital did not have an intensive care unit. 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 fixed wing air transport and mileage have been met. Therefore, we decided that the Plan has to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on January 3, 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 pre-approve a core buildup, including any pins when required (D2950) for tooth #18.
You asked the Plan to pre-approve the core buildup. You say that due to distal fracture and compromised margins, the enrollee has extreme sensitivity and discomfort when masticating, causing a toll in his overall health. The Plan denied your request. The Plan says the provided x-ray shows sufficient remaining tooth structure that has not been impacted by bruxism allowing restoration with a crown without the need for a core buildup.
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 core buildup 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 core buildup. Our reviewer says that a core buildup for tooth #18 is not medically reasonable and necessary. Our physician reviewer found the provided x-rays and photos reveal a minimally damaged distal aspect of #18, which when prepared for a crown would be incorporated into the preparation without a need for any buildup material. The amount of tooth reduction required for a crown preparation would encompass any noted damaged structure and there would be no room to retain any core buildup material. A core buildup is considered necessary where there is extensive loss of coronal structure such that a crown would not be able to be retained without it, this threshold usually found to be where more than 50% of the structure is missing. Our reviewer also found that in this case, where the basic crown preparation would encompass the missing or damaged areas, there clearly would be no need for a core buildup. 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 core buildup have not been met. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the binocular microscopy test you had on August 4, 2021.

You asked the Plan to waive the copayment for the binocular microscopy test. You say that you already paid your office visit copayment and would appreciate assistance with this bill because you are a senior citizen. The Plan denied your request. The Plan says you were charged this copayment 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 $25 copayment for diagnostic procedures and tests. 

You have been asked to pay a $25 copayment for the binocular microscopy test. The binocular microscopy test falls within the diagnostic procedures and tests 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 binocular microscopy test you had on August 4, 2021.