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

We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site
(D4266) and bone replacement graft for ridge preservation - per site (D7953) provided July 6, 2021.
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that you do
not believe you received guided tissue regeneration services, and therefore should not be responsible for the
cost. The Plan denied your request. The Plan says these services are not covered under your benefits.
Additionally, the Plan confirmed that the services billed were received.
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. We reviewed the included medical records and verified that they show
that the guided tissue regeneration was completed. Therefore, we decided that the Plan does not have to pay for
the guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge
preservation - per site (D7953) provided July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that the swelling in your legs has increased. The Plan denied your request. The Plan says the requested stockings are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 pre-approve compression stockings identified with code A6549.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99215) transthoracic echocardiography, to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you would like to have these services completed by this doctor. You would like to see the provider that you feel the most comfortable with due to your current health conditions. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 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 the outpatient office visit (99215) transthoracic echocardiography, to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower extremity prosthesis to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the lower extremity prosthesis. You say that the location you used to go to has closed permanently. 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 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 the lower extremity prosthesis to be provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power chair car lift purchased July 1, 2021.
You asked the Plan to pay for the power chair car lift. You say that you are requesting reimbursement for the
scooter lift. The Plan denied your request. The Plan says enrollee's must receive their medical services from an
in-network provider with the exception being urgent or emergent services. This item is not a Medicare covered
benefit.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the power chair car lift purchased July 1,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248).
You asked the Plan to pre-approve the non-intravenous conscious sedation. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve non-intravenous conscious sedation (D9248).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a periodontal scaling and root planing (D4342) of the
upper right quadrant.
You asked the Plan to pre-approve the scaling and planing. You say that it has been over seven years since you
had a cleaning of this nature, and it is well past the two-year time limit. The Plan denied your request. The Plan
says this treatment is covered but has a two-year time limit before it can be redone. The Plan also says that the
two-year time limit has not yet passed.
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, any combination of periodontal scaling
and root planing (D4341 or D4342) is limited to up to 4 quadrants every 2 calendar years. The record shows
that the provider billed for a periodontal scaling and root planing (D4342) of the upper right quadrant twice.
Therefore, we decided that the Plan does not have to pre-approve a periodontal scaling and root planing
(D4342) of the upper right quadrant.
Please Note: The Plan believes that the provider billed for the periodontal scaling and root planing (D4342) of
the upper right quadrant twice in error, when the lower right quadrant should have been billed instead. The Plan
also says that they contacted the provider's office about this issue, but the office was closed and has yet to
return the call. Please contact the provider and ask them to confirm with the Plan whether this service was
incorrectly billed twice for the upper right quadrant.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a physical therapy evaluation (97163) and therapeutic
exercises (97110) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve outpatient physical therapy (PT). You say that it was recommended for a
physical therapy who treats her condition. You say that there is a facility that is out of network, but it keeps
getting denied. You also say that the in network provider that you were referred to is too far as you do not
drive. You also say that The Plan denied your request. The Plan says there are in network providers available
that can 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 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
a physical therapy evaluation (97163) and therapeutic exercises (97110) to be provided by an out-of-network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second facet joint injection, or medial branch block
(MBB).
You asked the Plan to pre-approve the second MBB. You say that your pain has made it so that you are unable
to work. You feel that the injection provided sufficient relief and that you should be allowed to try the ablation
procedure to obtain long term relief. The Plan denied your request. The Plan says you did not obtain sufficient
relief from the first injection to support the need for a second.
The Plan follows Medicare rules. Medicare rules say that a confirmatory diagnostic MBB is covered only when
the first treatment provides at least 80% pain relief.
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 second MBB. Our reviewer says
that the LCD criteria for the second MBB procedure are not met, meaning this is not medically necessary. Our
physician reviewer found the enrollee has chronic low back pain. She has had epidural steroid injections and
tried medical marijuana without relief. She underwent diagnostic bilateral MBBs at L4/L5 and L5/S1 and
obtained 60% pain relief. The LCD requires at least 80% pain relief from each set of diagnostic MBBs. This
was not achieved, and therefore, the request is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the second MBB have not been met. Therefore, we decided that the Plan does
not have to pre-approve a second facet joint injection, or medial branch block (MBB).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you have one person who can transport you to and from appointments, and this is your provider as well. You also say that you are not asking just to go out-of-network, you have had many providers in-network and have had years of struggles with providers finding a good fit. The Plan denied your request. The Plan says this provider is a non-preferred provider for the services requested and your Plan covers out-of-plan services for urgent or emergency services only.
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 office visits. Our reviewer says that this does not meet criteria. Our physician reviewer found based on the medical records provided, there is no documentation that requested out-
of-network care is urgent or emergent to meet the health plan's criteria for coverage as opposed to care with an equally licensed and certified in-network provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office visits 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 office visits. Therefore, we decided that the Plan does not have to pre-approve office visits 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 pre-approve a porcelain crown (D2740) for tooth # 13.
You asked the Plan to pre-approve a crown. You say that the crown is necessary. The Plan denied your request.
The Plan says crown is not listed as a covered service.
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 crown is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain
crown (D2740) for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement calf pad.
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the code
cannot be requested separately.
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 E0995 is Wheelchair accessory, calf rest/pad,
replacement only, each. We find that CPT code E0995 is included in the approved power wheelchair and not
separately payable. 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 pre-approve a replacement calf pad.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture (D0364), and an endosteal implant (D6010) to be provided by a participating provider.
You asked the Plan to pre-approve a cone beam CT capture and an endosteal implant. You say that you have not been able to eat solid food in a year. You say that you want the Plan to pay for this. The Plan denied your request. The Plan says the requested dental work is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam CT capture (D0364), and an endosteal implant (D6010) to be provided by a participating provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance response and treatment, no transport (A0998) provided March 15, 2021.
You asked the Plan to waive the copayment for the ambulance response and treatment. You say that you were not transported. The Plan denied your request. The Plan says the copayment was 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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for the ambulance response and treatment. The ambulance response and treatment falls within the Ambulance services benefit category. This means that you have been asked to pay less than or equal to 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 ambulance response and treatment, no transport (A0998) provided March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3010, L3216).
You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary for your
condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3010, L3216).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a specialist consultation. You say that this provide performed a surgery for the enrollee in the past and she wants to continue to see this provider. The Plan denied your request. The Plan says this member has no urgent or emergent need, and she is not receiving dialysis for her to obtain medical services out-of-network when there are in-network providers available. The Plan also says that based on the records received, it was determined that this is not an emergency and there are providers within the Plan for a consultation with an orthopedic surgeon.
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 preapprove 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 preapprove these items/services.
Therefore, we decided that the Plan does not have to pre-approve a specialist consultation to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on June 25, 2021, to July 6, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you believe the Plan
should pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $265
copayment per day for days 1-8. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $265 copayment per day for days 1-8. There is a $0 copayment for additional
days for an inpatient hospital stay. The total amount you are being asked to pay is $2,120 ($265 x 8 days =
$2,120). These services are not being denied. An inpatient hospital stay falls within the inpatient hospital care
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 an inpatient hospital stay
provided by a participating provider on June 25, 2021, to July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on February 11, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Coronavirus test (U0002) provided on August 9, 2021.  You asked the Plan to pay for the Coronavirus test. You say that you got a Coronavirus test at the airport in order to travel internationally. You also say that you wanted to know for medical reasons. The Plan denied your request. The Plan says this service is not covered.  The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as business establishments are not covered by Medicare.  We looked at the file and Medicare rules. This testing was required by the airline for the purposes of routine travel. Based on this information, we decided that Medicare rules for coverage of the Coronavirus test have not been met. Therefore, we decided that the Plan does not have to pay for the Coronavirus test (U0002) provided on August 9, 2021.