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

We decided that the Plan does not have to pre-approve the gingivectomy or gingivoplasty (D4212).
You asked the Plan to pre-approve the gingivectomy or gingivoplasty. You say that the tooth is bad in your mouth and it can affect your health. The Plan denied your request. The Plan says the requested service is not listed as a covered service per the members plan coverage.
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 the gingivectomy or gingivoplasty (D4212).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services coded 45382 provided on May 5, 2021.

You asked the Plan to pay for the colonoscopy services. 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 45382 for the colonoscopy services has a bundled relationship with code 45385 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 colonoscopy services coded 45382 provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (72192) provided on March 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 72192 has a bundled relationship with code 74176 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 services (72192) provided on March 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 19, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's physician and document in the patient's medical record the date of consultation or, if attempts to consult did not succeed, the date and manner of notification to the physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided medical records do not document a consultation with or notification of the enrollee's primary care or attending physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for this enrollee because they need continued care for their complex medical needs. The Plan denied
your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is not required to
discharge elsewhere to receive ongoing acute level care. Acute care hospitals and LTACHs are licensed to
provide the same level of care, so there is no advantage in moving the enrollee to an LTACH. All services that
would be provided in the LTACH are already being provided and covered in the current setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee appears to be improving and only requires short-term additional
acute care services for stabilization which can safely be provided in the current facility. The enrollee does not
require services at the LTACH that are not already available and covered at the current facility. Therefore, the
request for transfer to an LTACH will be considered not medically necessary at this time. Transfer to a lower
level of care may be considered when treatment has completed.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82947, 84155, 84520,
85014, 85018, 85049, 36415, 84132, 84295, 84436, 84479, 86001, 83036, 82565, 84443, 85027, 82306,
80050) provided to the enrollee on October 5, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 82947,
84155, 84520, 85014, 85018, 85049, 36415, 84132, 84295, 84436,84479, 86001, 83036, 82565, 84443, 85027,
82306 remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the
specimen was collected on October 5, 2020, and received by the lab on October 6, 2020. Of note, the patient
resides in Texas (TX) and the billing laboratory is located in Pennsylvania (PA); therefore, the billed code
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.
Furthermore, Code 80050 is excluded by Medicare and therefore not payable by Medicare. Therefore, we
decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82947, 84155, 84520,
85014, 85018, 85049, 36415, 84132, 84295, 84436, 84479, 86001, 83036, 82565, 84443, 85027, 82306,
80050) provided to the enrollee on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.

You asked the Plan to pre-approve the requested services. You say that the procedure fills a treatment gap for those who do not receive adequate relief from conservative methods. The Plan denied your request. The Plan says there are not enough studies on the Intracept procedure to show 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 file shows that an intracept procedure for intraosseous ablation of the basivertebral nerve was requested. 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 requested services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.

Our physician reviewer found that the intracept procedure remains experimental. More research is needed to show safety and efficacy for treating 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance service (A0425, A0427) provided on April 20, 2021.

You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to the service provided.

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 combined yearly deductible of $500. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services. Once you have paid your combined deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the plan year. 

You have been asked to pay $457.23 for the deductible applied for the ambulance service provided. This is the Plan's allowed amount for this service which is less than the applicable yearly deductible. 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 deductible for the ambulance service (A0425, A0427) provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 1, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362, and L36523 to support their denial. However, LCD L36139, L36129, L36362, and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129, L36362, and L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) to be rendered by an OON provider.
You asked the Plan to pre-approve the crown. You say that you have been going to this provider for several years because you trust their work and have complete confidence in them. You also say that you should receive dental coverage whether the provider is in-network or OON because you pay for dental insurance. The Plan denied your request. The Plan says going to an OON provider is not medically necessary because your needs can be met in-network.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetes outpatient self-management training services received on April 30, 2021.
You asked the Plan to pay for the diabetes outpatient self-management training services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received exceed your benefit limit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. While the records do show that you suffer diabetes, the plan benefit for the diabetic self-management training is up to 10 hours (to be billed in 30 minute increments) of initial diabetes self-management training within a 12-month period. Review of the file shows that you have exceeded this benefit limit. Therefore, we decided that the Plan does not have to pay for the diabetes outpatient self-management training services received on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on May 6, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained for this lab work.
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 lab work provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication in the medical records that three months of non-operative therapy was prescribed or attempted.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this surgery remains experimental. More research is needed to show safety and efficacy.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and debridement services provided on August 18, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care and debridement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 subsequent nursing facility care and debridement services provided on August 18, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).
You asked the Plan to pre-approve the mandibular partial denture. You say that you need this partial to be approved for coverage because the partial you have is broken. The Plan denied your request. The Plan says the information sent in must show 1 or more front teeth missing or less than 8 teeth that are biting against each other, not including wisdom teeth. The Plan also says that you would have to meet all of the rules before this could be approved.
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 mandibular partial denture when the services are medically necessary and reasonable.
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 mandibular partial denture. Our
reviewer says that the mandibular partial denture is not medically reasonable and necessary for the enrollee.
Our physician reviewer found the Plan allows for partial dentures in cases where there are less than eight
posterior teeth in contact. Tooth #18 is tipped mesially, reducing the space that #19 once occupied. The Criteria
presented under the Policy states that the member must show one or more front teeth missing or less than eight
teeth biting against each other. Our reviewer found that in this instance, there are six sets of teeth in contact
making for twelve points of contact. Our physician reviewer also found that given the criteria, there are
sufficient contacts available and no medical necessity for the requested partial denture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the mandibular partial denture have not been met. Therefore, we decided that
the Plan does not have to pre-approve a mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is medically necessary The Plan denied your request. The Plan says the requested admission to an LTACH does not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and only requires short-term additional acute care services which can be safely provided at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be improving and only require short-term additional acute care services for stabilization which can be safely provided at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 14, 2021.
You asked the Plan to pay for the services provided. You say that the services should have been paid. The Plan
denied your request. The Plan says the service is not allowed separately.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
code 99053 is Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic
service. We find that CPT code 99053 is a bundled service. No separate payment is made for bundled codes.
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 medical services provided on May 14,
2021.