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

 We decided that the Plan does not have to pay for an office visit (99214, 3075F, 3079F) provided on August 31, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says these services were not authorized, and prior authorization was not obtained by the provider or facility. The Plan has also confirmed that this is not an ambulance service, emergency and urgently needed, post stabilization care, nor dialysis while outside of the service area. The Plan also says that these services were rendered and referred by a non-participating 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 an office visit (99214, 3075F, 3079F) provided on August 31, 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 exam (D0150) and panoramic x-ray
(D0330) provided on October 6, 2021.
You asked the Plan to pay for the comprehensive exam and panoramic x-ray. You say that these services were
necessary because this is a new dentist. The Plan denied your request. The Plan says You had a previous
comprehensive exam and complete series of x-rays provided in October of 2020. Comprehensive exams are
covered once every three years and you may receive one panoramic x-ray or complete series of x-rays every
five years. The services provided on October 6, 2021, exceed the benefit limitations for these services.
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 can cover one
comprehensive oral evaluation or one periodontal exam every three years. The Plan can also cover one
complete series of x-rays or one panoramic x-ray every five years.
Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a
frequency greater than what is covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the comprehensive oral exam (D0150) and panoramic x-ray (D0330) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint injection services on a third level.
You asked the Plan to pre-approve lumbar facet joint injection services on a third level. You say that the
clinical information provided supports the need for the injection services which remain in dispute. The Plan
denied your request. The Plan says coverage is limited to 2 levels either bilaterally or unilaterally.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered
under unique circumstances and with sufficient documentation of medical necessity on appeal.
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 lumbar facet joint injection services on
a third level. Our reviewer says that the criteria for coverage of a third level injection have not been met. Our
physician reviewer found there are not unique circumstances that make a third level procedure medically
necessary at this time. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of lumbar facet joint injection services on a third level have not been met.
Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint injection services on a third
level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided on July 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the acupuncture. You say that you are asking to be reimbursed for the acupuncture. The Plan denied your request. The Plan says the provider is 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for acupuncture provided on July 19, 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 consultation (D9310) provided on June 11, 2021.  You asked the Plan to pay for the dental service. You say that this should have been reviewed as a medical claim instead of dental. You say that you had to have a cyst removed from your gum and sent to a pathologist. You also say that if this is cancerous, you want to be sure that this will be paid by your plan. The Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan says that this claim is not for the cyst removal procedure, but for the initial consultation.  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 consultation is not among those covered under this benefit. The file shows that this claim is not for the cyst removal procedure, but for the initial consultation. The provider billed it as a dental consult. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on June 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment of distal radial fracture (25609) provided on July 29, 2021.
You asked the Plan to pay for the open treatment of distal radial fracture (25609). You say that the emergency room report shows the patient fell and was rushed to the hospital. You say that you hope the documents are enough for the claim to be considered for additional reimbursement. The Plan denied your request. The Plan says CPT code 25609 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 CPT code. In this case, the CPT Code Manual definition of code 25609 is open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments.
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 open treatment of distal radial fracture (25609). 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 enough detail to confirm treatment of 3 or more fragments therefore, this procedure cannot be confirmed.
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 open treatment of distal radial fracture (25609) have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of distal radial fracture (25609) provided on July 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve out-of-network physical therapy.  

You asked the Plan to pre-approve out-of-network physical therapy. You say that the patient does not feel comfortable going to in-network providers. You say that the Medicare allowable will be accepted if authorization is provided. The Plan denied your request. The Plan says in-network providers are available.  

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 out-of-network physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of impacted tooth (D7230), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) provided on August 31, 2021.  You asked the Plan to pay for the removal of impacted tooth, deep sedation/general anesthesia, and therapeutic parenteral drug. You say that you would like a copy of the invoice that was submitted with all the definitions for the codes at appeal (D7230, D9222, D9223, and D9610). You also say that you would like to know what identifies as an impacted tooth and the difference between pulling a tooth versus pulling a wisdom tooth. The Plan denied your request. The Plan says these services are not covered benefits 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 removal of impacted tooth (D7230), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) provided on August 31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there is not
enough information to support a SNF level of care.
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 services. Our physician reviewer
found that the documentation does not support that you need the skilled nursing services of a skilled
professional nurse to provide medically necessary treatment in a SNF. The documentation does not reveal
evidence of complex wound care, new enteral feedings, or other skilled nursing needs at this time. The
documentation does not reveal updated therapy notes indicating that your functional level requires skilled
therapy services in a SNF. The documentation does not support that you require skilled nursing or skilled
therapy services on a daily basis in a SNF or as a practical matter in a skilled nursing facility setting.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a physical therapy (PT) re-evaluation visit (97164) and a PT visit (97162) provided on August 6, 2021, to August 13, 2021.
You asked the Plan to waive the copayment for a PT re-evaluation visit and a PT visit. You say that you disagree with the copayment charged for your physical therapy visits, because the evaluation and the first session is not supposed to have a copayment when there is a diagnosis of back pain. You have a diagnosis of low back pain in your chart. You also say you would like to have the copayment waived or the claim re-processed to reflect the $0 copayment. The Plan denied your request. The Plan says you had PT services performed on April 5, 2021 and May 7, 2021 with no copayment applied. The Plan also says the copayment you are being charged is correct.
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 if you have been diagnosed with back pain, you pay a $0 copayment for an initial PT evaluation and a $0 copayment for your first PT session. Your contract with the Plan also clearly says that you must pay a $20 copayment for each outpatient rehabilitation services thereafter. You have been asked to pay a $20 copayment for a PT re-evaluation visit and a PT visit. The records show that you had a PT re-evaluation visit and a PT visit performed on April 5, 2021, and May 7, 2021 with a diagnosis of back pain. The records also show that the Plan applied your benefit of $0 copayment for the initial evaluation and a $0 copayment for your first PT visit. The EOC confirms that $20 is the required copayment for each PT visit after May 7, 2021. 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 physical therapy (PT) re-evaluation visit (97164) and a PT visit (97162) provided on August 6, 2021, to August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (procedure code 81455) provided to the enrollee on July 9, 2021.
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says this testing will be denied automatically as not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that procedure code 81455 will be denied automatically as not medically necessary. Medicare considers the denied testing to not be helpful in the management of patients. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (procedure code 81455) provided to the enrollee on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthoses (AFOs) and heel stabilizers provided
on February 1, 2021.
You asked the Plan to pay for the AFOs and heel stabilizers. You say that this was medically necessary. The
Plan denied your request. The Plan says the records do not support this claim.
The Plan must follow Medicare rules. Medicare rules say that suppliers must submit sufficient information to
corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage
criteria have been met.
In this case, the records provided do not include any mention about the ordering of AFOs or heel inserts. There
is no documentation of a diagnosis of the foot/ankle that would warrant these items. Without a note from the
ordering provider in which the need for the rendered items is discussed, it cannot be confirmed whether Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the ankle-foot
orthoses (AFOs) and heel stabilizers provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical collar (L0180) provided January 27, 2021.
You asked the Plan to pay for a cervical collar. You say that this item was medically necessary. The Plan
denied your request. The Plan says the billed service is not supported for payment.
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 a cervical collar. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation submitted did not include a valid physician order. The requested item is not
medically necessary for the enrollee in this case.
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 cervical collar have not been met. Therefore, we decided that the Plan does
not have to pay for a cervical collar (L0180) provided January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on April 13, 2021, by the out of network dentist.
You asked the Plan to pay for the dental services. You say that you listed dental benefit shows a $0 copayment
for exams, cleanings, x-rays, and fluoride. The Plan denied your request. The Plan says if you choose to see an
out of network dentist you might be billed for charges above what the plan pays, even for services listed as $0
copayment.
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 dentists may bill you for any amount greater than what the Plan pays. Therefore, we decided
that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided
on April 13, 2021, by the out of network dentist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for wigs (A9282) provided on July 28, 2021.  You asked the Plan to pay for wigs. You say that state law says that if you have alopecia due to chemotherapy and radiation and have a prescription for a hair prosthesis you are entitled to a reimbursement. The Plan denied your request. The Plan says the requested items are not a covered benefit.  Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.  In this case, although a wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for wigs. Therefore, we decided that the Plan does not have to pay for wigs (A9282) provided on July 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need more therapy and cannot walk. You
say that you are not a candidate for surgery and need to get your upper body strength up. The Plan denied your
request. The Plan says the enrollee has improved in his functional abilities and now requires moderate to
minimal assistance for transfers complicated by instability due to leg length discrepancy.
The Plan says that the enrollee has been medically stable. The Plan says that the guidelines for coverage of
SNF care have not been met.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely
and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date.
The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. The
enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and
judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable
treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination
of these services) on a "daily basis" in a SNF. As a practical matter the enrollee does not require the necessary
services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Reader and Sensor.
You asked the Plan to pre-approve the Freestyle Libre 14 Day Reader and Sensor. The Plan denied your
request. The Plan says you do not meet the prior authorization criteria requirements.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Medical records were not submitted with this case, and the record
shows that they were requested multiple times. Based on this information, we decided that Medicare rules for
coverage of the Freestyle Libre 14 Day Reader and Sensor have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Freestyle Libre 14 Day Reader and Sensor.