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

We decided that the Plan does not have to pre-approve breast reconstruction revision.

You asked the Plan to pre-approve breast reconstruction revision. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that breast reconstruction services are only covered for certain indications.

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 breast reconstruction revision. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee underwent breast implants following surgery for breast cancer. The record does not indicate that the enrollee has an enumerated condition for which surgery upon
breast implants is considered a covered service. The requested service is cosmetic. The elements of the coverage criteria are not satisfied. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of breast reconstruction revision have not been met. Therefore, we decided that the Plan does not have to pre-approve breast reconstruction revision.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93971) provided January 13, 2021.
You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed.
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 93971 has a Column One/Column Two relationship with code 93970 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 a duplex scan (93971) provided January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral exam (D0140), periapical x-ray
(D0220), the bitewing x-ray (D0270), and the occlusal adjustment (D9951) provided on January 11, 2021.
You asked the Plan to reimburse you for the dental services. You say that there would not be any duplication or
conflict if this claim had been submitted on time with the correct codes. You say that the dentist office manager
refused to change any dental code. You also say that this appointment was for a medical reason, and it should
be covered. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered
service. The Plan says that occlusal adjustment is not listed as a covered service either. The Plan says that 1 set
of bitewing x-rays are covered per calendar year. The Plan says that 1 periapical x-ray is covered per calendar
year. The Plan also says that the frequency limits have 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, the limited oral evaluation and occlusal
adjustment are not among those covered under this benefit. Although bitewing x-rays and periapical x-rays are
listed as covered services, the frequency limits have been exceeded. The record shows that the Plan paid for
bitewing x-rays that you received on February 23, 2021. The record also shows that the Plan paid for a
periapical x-ray that you received on February 3, 2021. Therefore, we decided that the Plan does not have to
reimburse you for the limited oral exam (D0140), periapical x-ray (D0220), the bitewing x-ray (D0270), and
the occlusal adjustment (D9951) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee requires an 
evaluation of her conditions and follow-up treatment. You say that the enrollee does not have any other form of 
transportation. You also say that she does not have financial or family resources to assist her in medical
appointments. The Plan denied your request. The Plan says the enrollee has used all of the benefit provided 
under their coverage. 
 
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 routine transportation trips (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment of swallowing dysfunction and/or oral function for feeding services coded 92526 provided on December 10, 2019.
You asked the Plan to pay for treatment of swallowing dysfunction and/or oral function for feeding 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 payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of treatment of swallowing dysfunction and/or oral function for feeding services have not been met. Therefore, we decided that the Plan does not have to pay for treatment of swallowing dysfunction and/or oral function for feeding services coded 92526 provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skin graft services provided on March 17, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code is not supported in the medical records.
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 15271 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. We asked our coder 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 services provided. Our reviewer found that the medical records do not include sufficient documentation to validate that code 15721 was performed. The description of services is not included in the operative note.
We looked at this coder'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 pay for skin graft services provided on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure.
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is 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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational as the role of this therapy is still not defined in the management of lumbar spinal stenosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the out-of-network podiatry services you
received on March 25, 2021.

You asked the Plan to waive the deductible for the out-of-network podiatry services. You say that you made an
appointment to get your toenails cut. You said that you paid your $45 copayment but were then billed an
additional $66.67. You stated that you do not think this is fair because you were in the office less than ten
minutes. The Plan denied your request. The Plan says you were charged this deductible correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1500 deductible which applies to out-of-network services.

Since you received these podiatry services from an out-of-network provider, the deductible applies to these
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1500
deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not
been met at the time the services in question. Therefore, we decided that the Plan does not have to waive the
deductible for the out-of-network podiatry services you received on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of a broken tooth, per tooth, (D5640) 
provided on June 15, 2021. 
 
You asked the Plan to pay for the dental service. You say that you had a tooth break off your denture. You also 
say that you are not able to pay this bill. The Plan denied your request. The Plan says replacement of broken 
tooth is not listed as a covered service. The Plan also says that you did not contact them prior to the date of 
service to verify benefits or provider eligibility. 
 
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 replacement of broken tooth is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
replacement of a broken tooth, per tooth, (D5640) provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics provided on April 14, 2021.
You asked the Plan to pay for the foot orthotics. You say that you were told these would be covered. The Plan
denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for the foot orthotics provided on April 14,
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on April 27, 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 seeing this enrollee because it is the nursing facility's responsibility to get authorization for their patients. You also say that the treatment provided was medically necessary. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that 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 provided on April 27, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transitional care management services provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for care and services. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the transitional care management services provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head/brain (70450) 
provided on May 8, 2021. 
 
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level 
of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because a procedure-to-procedure (PTP) edit exists between codes 70450 and 70496 and this code has not been 
billed with an appropriate modifier. 
 
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 CT 
scan 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid 
as a separate line item without an appropriate modifier, which was not billed on this claim. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for a computed tomography (CT) scan of the head/brain (70450) provided on May 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you cannot find anyone in-network who can provide these services. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 specialist services to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on May 30, 2021.

You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for diagnostic radiology services provided on May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 7, 2021.

You asked the Plan to pay for the comprehensive oral evaluation. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.

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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 12, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the online digital evaluation and management service provided on March 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the online digital evaluation and management service. You say that this service is a covered benefit. The Plan denied your request. The Plan says no prior authorization was 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 online digital evaluation and management service provided on March 9, 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 the group 3 power wheelchair with multiple power
options and multiple accessories.
You asked the Plan to pre-approve the group 3 power wheelchair with multiple power options and multiple
accessories. You say that this equipment is medically necessary for the enrollee's condition. The Plan denied
your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair with multiple power
options is subject to the criteria listed in the Medicare rules.
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 group 3 power wheelchair with
multiple power options and multiple accessories. Our reviewer says that the requested group 3 power
wheelchair with multiple power options is not medically reasonable and necessary. Our physician reviewer
found the patient does not meet the coverage criteria for a power tilt and power recline seating system (E1007).
There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure
ulcer. As the group 3 power wheelchair with power tilt (E1007) is not medically necessary the entire request
for multiple power options and accessories (K0861, E1028, E1007, E1012, E1028, E0953, E2377, E2313,
E2311, E2615, E0955, E1028, E2624) is not medically 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 the group 3 power wheelchair with multiple power options and multiple
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 3
power wheelchair with multiple power options and multiple accessories