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

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on March 3,
2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore,
we decided that the Plan does not have to pay for the drug testing services (G0482) provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the elbow brace (L3761).  You asked the Plan to pay for the elbow brace. You say that the item should be covered. The Plan denied your request. The Plan says there is not face to face encounter on file.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.      The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no documentation of a face-to face encounter. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the elbow brace (L3761).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound coded 76770 provided on September 8, 2021.  You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that code 76770 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76770 provided on September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray provided on August 23, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 71045 was billed with code 36556. We looked at the file and the rules. We find that CPT code 71045 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on April
5, 2021, by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that authorization was not obtained
prior to this enrollee being seen because it is the nursing facility's responsibility to get authorizations for their
patients. You also say that the services rendered were medically necessary, and you did not know the facility
failed to obtain a prior authorization for this enrollee. The Plan denied your request. The Plan says this service
was rendered by an OON provider and prior authorization was not obtained.

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.
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336)
provided on April 5, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on October 5, 2021.  You asked the Plan to pay for the dental service. You say that you had 2 teeth that needed to be fixed. You also say that you did not know that this would not be covered. The Plan denied your request. The Plan says that 1 periapical x-ray is covered every year. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on September 22, 2021. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacy services, supplies, laboratory services, and diagnostic services provided on June 9, 2021, and June 10, 2021, by an OON provider.  You asked the Plan to pay for the pharmacy services, supplies, laboratory services, and diagnostic services. You say that you are on a fixed income and the amount you were billed is beyond your ability to pay. The Plan denied your request. The Plan says these services were not referred or rendered by participating providers. The Plan also says that these services were not urgent or emergent, nor were they approved in advance.  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. Therefore, we decided that the Plan does not have to pay for the pharmacy services, supplies, laboratory services, and diagnostic services provided on June 9, 2021, and June 10, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve facet joint injections. You say that the Plan is not reading the clinical notes to support a denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show confirmed facet joint pain by noting two diagnostic medial branch blocks.  The Plan follows Medicare rules. Medicare rules state that therapeutic facet joint interventions may be covered under certain circumstances if the enrollee has had 2 confirmatory diagnostic medial branch blocks.  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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint radiofrequency ablation (RFA). Our physician reviewer found the enrollee never received a second set of diagnostic medial branch blocks (MBBs) as required by Medicare rules. Therefore, at this point the requested 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated scooter.  

You asked the Plan to pre-approve a power operated scooter. You say that you need a scooter due to having surgery on your hands and you cannot use you walker or crutches. The Plan denied your request. The Plan says you do not meet criteria for the requested device.  

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated scooter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 4, 2021, to April
6, 2021.
You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this claim to be
reconsidered for coverage. The Plan denied your request. The Plan says that the Medicare criteria for approval
of the inpatient hospitalization have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our
physician reviewer found the record show that at the time of inpatient admission the admitting physician
reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or
observation care) would span two midnights.
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 acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided from April 4, 2021, to April 6, 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.  You asked the Plan to pre-approve the additional PT visits. You say that you would like the additional therapy visits to be approved in order to continue progressing the enrollee back to her prior level of function. The Plan denied your request. The Plan says there is nothing in the supplied documentation that supports that the services will be of such a level of complexity and sophistication, or the condition of the patient will be such that the services required can be safely and effectively performed only by a qualified therapist or under a therapist's supervision, versus a home exercise program after the total approved visits.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the patient's condition. Our reviewer found that the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. Our physician reviewer also found that the requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
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 July 22, 2020.  You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you joined this plan because your dentist was a participant. You also say that neither you nor your dentist were aware that your dentist was not in-network for Medicare. The Plan denied your request. The Plan says services rendered by an OON provider are not covered. The Plan also says that this claim was received after the 365-day filing deadline.  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. Medicare rules also say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. The record also shows that a claim for the periodic oral evaluation and prophylaxis was not filed until August 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electric connection between power accessories (E2311).
You asked the Plan to pre-approve the electric connection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for this equipment.
The Plan follows Medicare rules. Medicare rules say that the electric connection is subject to the criteria listed 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 the electric connection.
Our reviewer says that the electric connection is not medically necessary. Our physician reviewer found the
patient has 2 power options included on the power wheelchair but the patient's upper extremity strength and
function support that the patient can control any power options through their own switches. The requested item
is not medically necessary as a result.
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 electric connection have not been met. Therefore, we decided that the Plan
does not have to pre-approve the electric connection between power accessories (E2311).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray provided on September 13, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says this was previously paid.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    We looked at the file and the rules. The file shows that CPT code 71045-26-77, with the same provider, was billed twice. The records show that this service was paid for once by the Plan. The records do not show that an additional test was performed by the provider at issue on this date of service. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6253), prefabricated abutment (D6056), and
abutment supported crown (D6058) provided from May 17, 2021, to August 24, 2021.
You asked the Plan to pay for the fixed bridge. The Plan denied your request. The Plan says fixed prosthetics
are 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 fixed prosthetic is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic (D6253),
prefabricated abutment (D6056), and abutment supported crown (D6058) provided from May 17, 2021, to
August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided August 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you were unaware that the provider was OON. The Plan denied your request. The Plan says services provided OON are 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. The Plan covers the dental cleaning, periodic oral exam, intraoral x-ray and bitewing x-rays when you visit a contracted provider to utilize covered dental benefits. We looked at the file, and Medicare rules. 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 periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided August 10, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on July 30,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the rendering provider was not participating.
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 chiropractic services provided to the enrollee on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical images (D0220 and D0230) provided by a participating provider on October 5, 2021.
You asked the Plan to pay for intraoral periapical images. You say that this should have a $0 copayment. The Plan denied your request. The Plan says D0230 and D0220 are not covered dental 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral periapical images (D0220 and D0230) provided by a participating provider on October 5, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing provided on August 9, 2021.
You asked the Plan to pay for the testing services. You say that the test was needed to travel. The Plan denied
your request. The Plan says tests required for work, sports, or travel are not a covered service.
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.
We looked at the file and the rules. The file does not show that the testing was ordered due to signs or
symptoms of coronavirus. The test at issue in this appeal was provided solely for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for the coronavirus testing provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (81542) rendered by the out-of-network (OON) provider on May 4, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81542) rendered by the out-of-network (OON) provider on May 4, 2021.