Persius/hicric huggingface dataset:
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 October 4, 2021.  You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you didn't receive a notice of dental changes and didn't know that you were not covered for your normal 2 cleanings. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the periodic oral exam and dental cleaning once per calendar year.   We looked at the file and Medicare rules. The Plan provided documentation showing that a periodic oral exam and dental cleaning were previously covered on February 8, 2021. Based on this information, we decided that the Plan's frequency limits for coverage of the periodic oral exam and dental cleaning have been exceeded. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist home visit provided on September 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist home visit. You say that services were provided to the enrollee and the proper steps to obtain authorization was not done prior to the service. The Plan denied your request. The Plan says the provider is an out-of-network provider and prior authorization was not approved.   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 a specialist home visit provided on September 24, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve inpatient psychiatric care from February 17, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 17, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically necessary.  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. Specifically, the record clearly indicates that the Plan utilized medical records to support their denial of continued services. We requested these medical records, and none were received. Without this clinical information we are unable to determine if the Plan's denial is substantiated. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan has not forwarded sufficient clinical information that was used to support their denial so we must find in your favor. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from February 17, 2022, forward.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tempus gene panel provided on May 10, 2021, billed with multiple codes.  You asked the Plan to pay for the Tempus gene panel as billed. You say that this is a medically necessary test that should be covered. The Plan denied your request. The Plan says this is not billed correctly for the services rendered.  The Plan must follow Medicare rules. Medicare rules say that billing targeted gene panels using individual gene codes is incorrect coding. A single CPT code that describes the panel must be used.   We looked at the Medicare rules and the file. We find that the claim for this testing was not coded in accordance with Medicare rules. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel provided on May 10, 2021, billed with multiple codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a platelet rich plasma (PRP) injection with autologous stem cells.  You asked the Plan to pre-approve the PRP and stem cell injection. You say that this should be covered since the enrollee wishes to avoid surgery. It is felt this is a medically necessary treatment. The Plan denied your request. The Plan says this remains experimental this time.  The Plan must follow Medicare rules. Medicare rules say that there is a lack of high-quality evidence to show that PRP is medically indicated in the treatment of any disorder at this time, aside from an approved clinical trial. Therefore, we decided that the Plan does not have to pre-approve a platelet rich plasma (PRP) injection with autologous stem cells.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on September 27, 2021, billed with code 70450.  You asked the Plan to pay for the CT interpretation as billed. You say that this should be paid as multiple exams were provided on the same date. The Plan denied your request. The Plan says an appropriate modifier was not used for the Column 2 code at issue.  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 70450 is a column II code to column I code 70496 which was billed by the same group practice. 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 interpretation of the computed tomography (CT) scan of the head provided on September 27, 2021, billed with code 70450.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the addition, endoskeleton system, below knee (BK), alignable system (L5910).  You asked the Plan to pre-approve the alignable system addition. You say that the item is medically necessary. The Plan denied your request. The Plan says the member was approved for a non-alignable prosthesis; the requested item is for an alignable system.  The Plan must follow Medicare rules. Medicare rules say that when a preparatory below knee prosthesis (L5510-L5530, L5540) is provided prosthetic substitutions and /or additional of procedures and components are covered in accordance with the functional level assessment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the alignable system addition have not been met. Specifically, the requested item is used with an alignable system, but the member was approved for a non-alignable prosthesis. Therefore, we decided that the Plan does not have to pre-approve the addition, endoskeleton system, below knee (BK), alignable system (L5910).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (0441T) provided August 23, 2021.  You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Insufficient clinical documentation was submitted to support the services billed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (0441T) provided August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intracept procedure, intraosseous basivertebral nerve ablation coded as C9752, 22899 and 64628.  You asked the Plan to pre-approve intracept procedure. You say that the pain has eliminated your ability to stand for longer than a few minutes. You are appealing the denial of the intracept procedure and allow you to return to your active life. The Plan denied your request. The Plan says this procedure is unproven, experimental and investigational. There are not enough studies on intracept to show that it is safe and effective.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept procedure, intraosseous basivertebral nerve ablation coded as C9752, 22899 and 64628.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory tests provided on October 15, 2021.  You asked the Plan to waive the copayment for laboratory tests. You say that the laboratory tests were part of your annual physical so you should not be charged for the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $5 copayment for laboratory tests.   You have been asked to pay a $5 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory tests provided on October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an oral splint.  You asked the Plan to pre-approve the requested item. You say that your jaw is painful. The Plan denied your request. The Plan says dental devices 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 services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested item is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an oral splint.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided March 5, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee brace and suspension sleeve provided on October 4, 2021, billed with diagnosis code M17.0.  You asked the Plan to pay for the brace and sleeve as billed. You say that this was medically necessary and correctly coded. The Plan denied your request. The Plan says the diagnosis codes reported on this claim are mismatched. As such, this claim is not correctly coded.  The Plan must follow Medicare rules. Medicare rules say that some codes indicate laterality. Bilateral codes should only be reported if the condition occurs on both sides.  Code M17.0 is bilateral knee osteoarthritis. The records provided do not show that this is a bilateral condition. The claim also reports a unilateral code which is contradictory. Based on the records and the other diagnoses reported on the claim, this does not meet ICD-10-CM billing guidelines. Therefore, we decided that the Plan does not have to pay for the knee brace and suspension sleeve provided on October 4, 2021, billed with diagnosis code M17.0.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device.  You asked the Plan to pre-approve the purchase of a CPAP device. You say that you need this item. The Plan denied your request. The Plan says that purchase of this item is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that the MAO is responsible for maintaining continuity of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME item, including when the item needs to be repaired or replaced. If necessary, the MAO must purchase or rent a replacement item for the beneficiary to use.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device.   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: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a lumbar spine computerized tomography (CT) scan.  You asked the Plan to pre-approve the CT scan. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says that advanced imaging, including an MRI (magnetic resonance imaging) of the thoracic and lumbar spine has already been approved in a separate letter. Without the results of the pending advanced imaging services, the requested CT scan is duplicative and not medically necessary at this time.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   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 CT scan. Our reviewer says that the requested CT scan is medically necessary in this case. Our physician reviewer found that while the already approved MRI exams will allow for evaluation of neural impingement, the CT scan will be necessary in order to optimally view the facet joints and the hardware from the prior fusion. An MRI will not provide such capability, and the addition of CT scanning is typical for patients with prior lumbar fusion and hardware who continue to have physical disability after lumbar fusion surgery.  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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve a lumbar spine computerized tomography (CT) scan.   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 discharge day management provided on June 23, 2021, billed with 99316.  You asked the Plan to pay for the discharge day management. You say that this was correctly billed based on the records provided. The Plan denied your request. The Plan says without documentation of time spent, the code cannot be verified.  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 99316 is Nursing facility discharge day management; more than 30 minutes.  We find that CPT code 99316 is not supported in the medical record. Specifically, there is no clear documentation of time spent with the patient. Based on this information, we decided that Medicare rules for coverage of the discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the discharge day management provided on June 23, 2021, billed with 99316.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for group psychotherapy services (90853) provided on August 16, 2021 to August 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy services. You say that you do not normally need a precert for this procedure code. Please review and reprocess. 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 group psychotherapy services (90853) provided on August 16, 2021 to August 17, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve freestyle test strips.  You asked the Plan to pre-approve freestyle test strips. You say that the item is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to use the requested item over the Plan's preferred items.  The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.  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 freestyle test strips. Our reviewer says that you do not need this item. Our physician reviewer found any meter can be used to measure the finger stick glucose; it does not need to be the libre meter with the neo strips.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of freestyle test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve freestyle test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a specialist office visit. You say that you had a bad experience with an in-network provider and would like to see a different specialist. The Plan denied your request. The Plan says the enrollee does not have to see the previous provider and that there are plenty of in-network providers who can provide the same service for the enrollee.  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 specialist office visit to be provided by an out-of-network (OON) provider.   Your complaint about your experience with this provider 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.