Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy for low back pain. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service provided on May 17, 2021.
You asked the Plan to pay for the ambulance service. You say that upon arrival all your vital signs were checked. You also say that they found everything to be normal and allowed you to return home. The Plan denied your request. The Plan says that your evidence of coverage does not provide benefits for this service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the medical records for this case. We asked for this information, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of payment. Therefore, we decided that the Plan has to pay for the ambulance service provided on May 17, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lightweight wheelchair (K0005) and sales tax (S999) provided on April 6, 2021.

You asked the Plan to pay for a lightweight wheelchair and sales tax. You say that your provider ordered the item and it should be covered. The Plan denied your request. The Plan says you purchased your item through a non-certified provider.

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 a lightweight wheelchair (K0005) and sales tax (S999) provided on April 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on February 9 to March 23, 2021, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for your care. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 psychotherapy services (90837) provided on February 9 to March 23, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the visit (99204) provided on May 5, 2021.

You asked the Plan to pay for the visit. The Plan denied your request. The Plan says the billed code is 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 99204 is "Office or other outpatient visit for the
evaluation and management of a new patient, which requires these 3 key components: A comprehensive
history; A comprehensive examination; Medical decision making of moderate 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 moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient
and/or family."

We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that the
visit in question was provided in the emergency department. It is inappropriate to bill code 99204 for an
emergency department visit. Based on this information, we decided that Medicare rules for coverage of the
visit have not been met. Therefore, we decided that the Plan does not have to pay for the visit (99204) provided
on May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 6, 2020, by an out-ofnetwork
provider.
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied
your request. The Plan says you did not request prior authorization as required.
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 services at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that
the Plan does not have to pay for the office visit provided on August 6, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for collection of venous blood by venipuncture (36415) provided
on April 12, 2021, by an OON provider.
You asked the Plan to pay for the outpatient services. You say that you maintain that this testing was necessary
and reasonable, based upon medical necessity of the care provided and the need for treatment. 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 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 collection of venous blood by venipuncture
(36415) provided on April 12, 2021, by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on May 3,
2021, by an OON provider.
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 rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on
May 3, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and comprehensive oral evaluation provided on April 21, 2021.
You asked the Plan to pay more for the prophylaxis and comprehensive oral evaluation. You say that you were given the name of this provider as an in-network dentist, but the office informed you the Plan would only pay 50% of the services. You say that it was not your fault you used an out-of-network dentist and the Plan should reimburse you the $159.50 that you paid. The Plan denied your request. The Plan says the claim processed correctly per your out-of-network benefits.
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 Plan is only obligated to pay 50% of the allowed amount for a prophylaxis and comprehensive oral evaluation from an out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the prophylaxis and comprehensive oral evaluation provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on May 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you have found that cold later treatments have been very helpful in controlling her pain level and provides significant relief in place of manual muscle work and manipulation. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on May 3, 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 periodic oral evaluation (D0120) and unspecified adjunctive procedure (D9999) provided on February 22, 2021.
You asked the Plan to pay for the dental services. You say that this provider is the most accessible to you and these services should be covered. The Plan denied your request. The Plan says the provider in question does not participate in the Medicare program. Therefore, payment cannot be 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. The Plan can cover eligible dental services when they are received from a licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from providers who do not participate in Original Medicare are not covered under this benefit. Documentation shows that the provider in question has opted-out of participation with Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and unspecified adjunctive procedure (D9999) provided on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81407, 81408 and 81479) provided to the enrollee on January 14, 2021.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
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 enrollee had cardiovascular risk assessment testing on January 14, 2021. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81407, 81408 and 81479) provided to the enrollee on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
You asked the Plan to pre-approve a complete upper and lower denture. You say that the dentures are necessary because you are in pain and losing weight. The Plan denied your request. The Plan says you have exceeded frequency limits 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 covers a complete upper and lower denture once every five plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that a complete upper and lower denture were previously covered on April 30, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of a complete upper and lower denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF admission is not medically necessary based on lack of medical complexity, skilled rehabilitation nursing or therapy needs.
The enrollee's therapy needs can be addressed at a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of an erupted tooth provided on June 4, 2021.
You asked the Plan to pay for the extraction of an erupted tooth. You say that this was a simple removal of a
tooth that was half loose already. You say that you called to verify coverage and payment should be
reimbursed. The Plan denied your request. The Plan says surgical extractions are 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 pay for the
extraction of an erupted tooth provided on June 4, 2021. Your complaint about being misled about your coverage is not a valid appeal for medical coverage. This part of
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99212) radiologic examination,
spine, cervical; two or three views (72040) and radiologic examination, spine, lumbosacral (72100) provided
April 20, 2021.
You asked the Plan to pay for the chiropractic services. You say that you are requesting the denial of the office
visit to be reviewed through an appeal. The Plan denied your request. The Plan says these services are not
covered when rendered by a chiropractor.
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.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99212) radiologic examination, spine, cervical; two
or three views (72040) and radiologic examination, spine, lumbosacral (72100) provided April 20, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the therapeutic exercises provided on November 20, 2019.
You asked the Plan to pay for the therapeutic exercises. You say that the Plan is required to pay non-contracted
providers at the preferred rate if the services are not available from preferred providers. You say that the innetwork
benefits should be honored, and the claim processed for payment. The Plan denied your request. The
Plan says that an appropriate modifier was not billed with this code edit.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop
strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is supported in the medical record. Specifically, while CPT code 97110 has a
bundled relationship with CPT code 92526, there is no indication in the record that CPT code 92526 has been
paid. It is not appropriate to apply bundling rules when the column I code has not been paid. Based on this
information, we decided that Medicare rules for coverage of the therapeutic exercises have been met.
Therefore, we decided that the Plan has to pay for the therapeutic exercises provided on November 20, 2019.
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 the office visit (99212) and manual traction therapy (97012) provided on May 27, 2021 and June 2, 2021.
You asked the Plan to pay for office visit (99212) and manual traction therapy (97012). You say that the services have been covered in the past. The Plan denied your request. The Plan says chiropractic manipulation is covered but the remaining services are not covered when provided by a chiropractor.
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. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99212) and manual traction therapy (97012 provided on May 27, 2021 and June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two surgical implant placements (D6010) provided on May
13, 2021.
You asked the Plan to pay for the dental implants. You say that these services were necessary for your overall
health. The Plan denied your request. The Plan says these services are not covered by your dental 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 pay for the
surgical implant placements (D6010) provided on May 13, 2021.