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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you are not
ready to be discharged from the hospital.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer
found that the most recent therapy documentation indicates you continue to have difficulty working with
therapy due to dizziness. You are medically stable and do not have any complex daily wound care, parental
medications or required care for a feeding tube. Although you require further rehabilitation services to improve
function, you do not require skilled nursing or therapy services on a daily basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of partially bony impacted tooth (D7230), removal of completely bony impacted tooth (D7240), removal of completely bony impacted tooth with complications (D7241), primary closure of a sinus perforation (D7261), consultation (D9310), and therapeutic parenteral drugs (D9612), or pay more for the surgical extraction (D7210), and deep sedation/general anesthesia (D9222 and D9223) provided on May 18, 2021.
You asked the Plan to pay for the removal of partially bony impacted tooth, removal of completely bony impacted tooth, removal of completely bony impacted tooth with complications, primary closure of a sinus perforation, consultation, and therapeutic parenteral drugs, and to pay more for the surgical extraction, and deep sedation/general anesthesia. You say that prior to the services being rendered, you asked how much they would cost and were advised you would be responsible for $1,057.00. The Plan denied your request. The Plan says the removal of partially bony impacted tooth, removal of completely bony impacted tooth, removal of completely bony impacted tooth with complications, primary closure of a sinus perforation, consultation, and therapeutic parenteral drugs are not covered under your plan. The Plan also says that you have a 50% coinsurance for the surgical extraction and deep sedation/general anesthesia 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the removal of partially bony impacted tooth, removal of completely bony impacted tooth, removal of completely bony impacted tooth with complications, primary closure of a sinus perforation, consultation, and therapeutic parenteral drugs are not among those covered under this benefit. The contract clearly states that you are responsible for a 50% coinsurance for each surgical extraction (D7210) and deep sedation/general anesthesia (D9222 and D9223) service. Therefore, we decided that the Plan does not have to pay for the removal of partially bony impacted tooth (D7230), removal of completely bony impacted tooth (D7240), removal of completely bony impacted tooth with complications (D7241), primary closure of a sinus perforation (D7261), consultation (D9310), and therapeutic parenteral drugs (D9612), or pay more for the surgical extraction (D7210), and deep sedation/general anesthesia (D9222 and D9223) provided on May 18, 2021.
Please Note: The Plan contacted the treating provider and confirmed that they have written off all the balance above your payment of $1,000.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the testing described by codes 81201, 81317, 81403, 81404, 81405, 81406, 81407, 81408, and 81479. We decided that the Plan does not have to pay for the testing described by codes 81295 and 81298.
You asked the Plan to pay for the testing described by codes 81201, 81317, 81403, 81404, 81405, 81406, 81407, 81408, and 81479. You say that this is billed correctly and was medically necessary. The Plan says that two of the codes are not payable with 81432. The rest are not being addressed in this case.
We decided that the Plan has to pay for the testing described by codes 81201, 81317, 81403, 81404, 81405, 81406, 81407, 81408, 81432, and 81479.
The Plan follows Medicare rules. Medicare rules say that Plans must make reasonable and diligent efforts to forward information relating to denials of payment. The rules also say that unless explicitly excluded, services ordered by a network provider are deemed approved by the Plan. This testing was ordered by a network provider. The Plan did not provide a valid denial rationale for these codes. There is no clear issue with the billing for this testing. We find that the testing is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the testing described by codes 81201, 81317, 81403, 81404, 81405, 81406, 81407, 81408, 81432, and 81479.
We also decided that the Plan does not have to pay for the testing described by codes 81295 and 81298.
The Plan follows Medicare rules. Medicare rules say that when an NCCI edit exists between two codes, only the Column 1 code is payable. If the modifier indicator of the edit pair is 0, then there is no instance in which payment can be made for the Column 2 code. Though this testing is considered approved by the Plan, codes 81295 and 81298 are Column 2 codes in relation to 81432. The modifier indicator is 0. This means that the codes are mutually exclusive and cannot be paid when reported on the same date of service. As this is an example of incorrect billing, plan directed care cannot override this denial. Therefore, we decided that the Plan does not have to pay for the testing described by codes 81295 and 81298.
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 pre-approve the heel stabilizer (L3170).
You asked the Plan to pre-approve the heel stabilizer. You say that you had a diabetic foot ulcer that just
healed, and you cannot wait 3 months for shoes. You have worked with this provider for several years and they
have already made your shoes with inserts. The Plan denied your request. The Plan says the enrollee does not
have a brace and do not meet the Medicare criteria for the heel stabilizer. The heel stabilizer (L3170) is only
covered if it is part of a brace.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. The Medicare rules say that the heel stabilizer coded as L3170 can
only be approved if it is being used with a brace. The records do not show that you have a brace. Based on this
information, we decided that Medicare rules for coverage of the heel stabilizer have not been met. Therefore,
we decided that the Plan does not have to pre-approve the heel stabilizer (L3170).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says this procedure is considered experimental/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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a core buildup (D2950) provided on
May 24, 2021.

You asked the Plan to pay for a crown, and a core buildup. You say that you want the Plan to reconsider
coverage for these services. The Plan denied your request. The Plan says the services at issue are not covered
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 a crown
(D2740), and a core buildup (D2950) provided on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest and the CT scan of the abdomen and pelvis you had on May 7, 2021.
You asked the Plan to waive the copayment for the two CT scans. You say that you were put on the table twice because the technician wasn't happy with the images. You stated that because of this, you had two copayments apply. The Plan denied your request. The Plan says you were charged these copayments 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 $50 copayment for radiological diagnostic services. Records show that you had two different CT scans. You have been asked to pay a $50 copayment for each of the two CT scans. The CT scans fall within the radiological diagnostic services 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 the computed tomography (CT) scan of the chest and the CT scan of the abdomen and pelvis you had on May 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional non-emergent routine transportation trips (A0120).

You asked the Plan to provide coverage for additional routine transportation trips. You say that the enrollee has twenty (20) chemotherapy treatments left and ten (10) follow up visits. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. The records show that you have used fifty-six (56) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 trips are used, the benefit will be exhausted. Based on this information, we decided that Plan rules for coverage of additional transports have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional non-emergent routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 12, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910), gingival irrigation (D4921 x4), and topical application of fluoride (D1206) provided on February 3, 2021.
You asked the Plan to pay for periodontal maintenance, gingival irrigation, and topical application of fluoride. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered 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 periodontal maintenance (D4910), gingival irrigation (D4921 x4), and topical application of fluoride (D1206) provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 single power option wheelchair (K0856) and accessories (E0955, E2361, K0108, E1028, E2300, E2611).
You asked the Plan to pre-approve a group 3 single power option wheelchair and accessories. You say that the enrollee needs this because his previous wheelchair was struck by a train. The Plan denied your request. The Plan says the requirements for coverage of the specific requested wheelchair have not been met.
The Plan must follow Medicare rules. Medicare rules say that a group 3 single power option wheelchair is covered if the beneficiary requires a drive control interface other than a hand or chin-operated standard proportional joystick, the beneficiary meets coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair, or the beneficiary uses a ventilator which is mounted on the wheelchair. If the power wheelchair base is not covered, then related accessories will be denied. We looked at the file and Medicare rules. The records do not show that the enrollee requires a drive control
interface other than a hand or chin-operated standard proportional joystick, meets coverage criteria for a power tilt or a power recline seating system and the system is being used on the wheelchair, or uses a ventilator which is mounted on the wheelchair. Based on this information, we decided that Medicare rules for coverage of a group 3 single power option wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 single power option wheelchair (K0856) and accessories (E0955, E2361, K0108, E1028, E2300, E2611).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three additional physical therapy (PT) visits (97139).

You asked the Plan to pre-approve additional PT. You say that the records provided support the need for the number of physical therapy visits being requested. The Plan denied your request. The Plan says the requested number of visits are not medically necessary. The Plan says that it is anticipated that the enrollee will be further instructed in a vigorous home exercise program and will not need services at the level of complexity and sophistication required to be performed by a licensed therapist.

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 additional PT. 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. 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 enrollee'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 additional PT have not been met. Therefore, we decided that the Plan does not have to pre-approve three additional physical therapy (PT) visits (97139).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osseous surgery (D4261).

You asked the Plan to pre-approve osseous surgery. You say that these services are medically necessary. 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 pre-approve
osseous surgery (D4261).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency routine transportation.
You asked the Plan to pre-approve additional trips. You say that you need more trips to be approved. You also say that you have more appointments to go to this year. The Plan denied your request. The Plan says you have scheduled and used the maximum of 24 trips allowed per year. The Plan also says that no further trips are available.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intravenous hydration services provided to the enrollee on
April 30, 2020 and billed under code 96360.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare coverage criteria were not met. Maximus overturned the Plans denial. The
Plan requested a reopen and stated that Maximus did not apply the correct Medicare criteria. The Plan says that
based on Medicare LCD is based on services rendered in the region.
The services were rendered in the state of New Jersey, therefore the guidelines for LCD L34960 were correctly
applied and this claim cannot be paid as billed.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, code 96360
was not billed appropriately on this claim. Therefore, we decided that the Plan does not have to pay for
intravenous hydration services provided to the enrollee on April 30, 2020 and billed under code 96360.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve several surgical extraction (D7210), removal of residual
tooth roots (D7250) and removal of torus mandibularis (D7473).

You asked the Plan to pre-approve the dental services. You say that these services are medically necessary, and
you cannot eat without severe pain. The Plan denied your request. The Plan says they have approved two of the
extractions in a previous request, but the remaining extractions and tooth root removal requests exceed the
benefit's limit for the year. The requested removal of torus mandibularis is not 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 items or services are not
among those covered under this benefit or are requested in a frequency that exceeds what is covered by the
benefit. The Plan has indicated that you were previously approved for two extractions in 2021. The Plan can
cover a maximum of two extractions per calendar year. Therefore, we decided that the Plan does not have to
pre-approve several surgical extraction (D7210), removal of residual tooth roots (D7250) and removal of torus
mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6056) and an abutment supported crown (D6057).
You asked the Plan to pre-approve the dental services. You say that the enrollee has a medical condition that does not allow for a partial denture to be fitted. You also say that the services should be covered. The Plan denied your request. The Plan says custom fabricated abutment is not listed as a covered service. The Plan says that abutment supported crown is not listed as a covered service either.
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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6056) and an abutment supported crown (D6057).