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

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7 and 10.
You asked the Plan to pre-approve the crowns. You say that your dentist advised that these teeth are beyond repair and you would like the crowns approved for coverage. The Plan denied your request. The Plan says tooth #'s 7 and 10 do not appear to have significant breakdown due to decay or trauma. The Plan also says that the problem is a cosmetic one that can be resolved with replacing the existing bonding.
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 crowns 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 crowns. Our reviewer says that the crowns are not medically reasonable and necessary. Our physician reviewer found the restoration on tooth #7 is relatively small, with the restoration on tooth #10 being more extensive but appears to involve mostly the facial surface. It does not appear there is extensive structural breakdown of either tooth. Our reviewer found that the documentation indicates the provider had also noted the procedure would be for cosmetic concerns. Crowns are restorations and are usually reserved for situations where the tooth would be too weak to function without the additional support offered by this type of restoration. Our physician reviewer also found that, as there is no significant structural breakdown of either tooth, there would be no medical necessity for restoration with crowns on tooth #'s 7 and 10. 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 crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 7 and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) (CPT code 99153) provided to the enrollee on June 2, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says CPT code 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department.

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 service have not been met. Only the professional component of radiology/diagnostic services are made to the physician. CPT code 99153 is a TC only diagnostic code, payment may only be made to the facility. Therefore, we decided that the Plan does not have to pay for moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service) (CPT code 99153) provided to the enrollee on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on March 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.
Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 6, 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 will attempt to consult with the enrollee's
attending or primary care 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 records do not document an
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we
decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on June 9, 2021, from an out-of-network provider.

You asked the Plan to pay for the eyeglasses. You say that your spouse called the Plan and was told this provider was part of the Plan's network. You feel you should be provided the $100 eyewear discount and should not be penalized for misleading information. The Plan denied your request. The Plan says this provider is not part of the Plan's specified routine vision network. You must use a provider in the specified network to use these supplemental benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider within the Plan's specified routine vision network.

We looked at the file and the Plan's rules. The provider in question does not participate in the Plan's vision network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on June 9, 2021, from an out-of-network provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on November 26, 2020.

You asked the Plan to pay for the fixed wing air transport and mileage. You say that this transport was medically necessary for the enrollee. The Plan denied your request. The Plan says that the information provided does not support criteria for air ambulance transport for neurology services.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the fixed wing air transport and mileage. Our reviewer says that the air transport was medically reasonable and necessary for the enrollee. Our physician reviewer found the record indicates that the intubated enrollee required neurology consultation as well as continuous electroencephalogram (EEG) monitoring for presumed seizure disorder. The record indicates that the enrollee had previously been transferred out the hospital that was the Plan's suggested alternative, to the current facility. Our reviewer found that the record indicates that the enrollee required a higher level of care. Ground transportation of over 300 miles for an intubated patient is not medically reasonable. Our physician reviewer also found that the elements of the coverage criteria are satisfied. 

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 fixed wing air transport and mileage have been met. Therefore, we decided that the Plan has to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on November 26, 2020.

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 transtelephonic rhythm strip pacemaker evaluation single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report by a physician or other qualified health care professional, up to 90 days (93293) provided on May 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the cardiac device monitoring services. You say that the provider may not be a doctor that goes to the nursing home, but the services provided were medically necessary. You provided this service out of good faith. 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 the transtelephonic rhythm strip pacemaker evaluation single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report by a physician or other qualified health care professional, up to 90 days (93293) provided on May 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798) provided to the enrollee on August 19, 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 supported by the records.

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): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798 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 August 19, 2020, and received by the lab on August 21, 2020. Therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640 and 87798) provided to the enrollee on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device rendered on March 10, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows that the provider was not Medicare certified for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device rendered on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia supplies provided on February 9, 2021.

You asked the Plan to pay for the services provided. You say that the services deserve separate payment. The Plan denied your request. The Plan says the rules for payment have not been met.

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 codes S1015 and S8301 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.

The CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease. We find that code 99072 is a bundled code. No separate payment is ever made. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia supplies provided on February 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional home health physical therapy (PT) visits (G0151 x5).
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says the submitted clinical documentation does not establish the medical necessity for the requested therapy and does not meet Medicare criteria.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional PT visits. Our reviewer says that the requested home health PT visits are not medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled PT needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional home health physical therapy (PT) visits (G0151 x5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110), and a complete lower denture (D5120) provided on July 8, 2021.
You asked the Plan to pay for a complete upper denture, and a complete lower denture. You say that the services were necessary. 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 complete upper denture (D5110), and a complete lower denture (D5120) provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated post and core in addition to crown (D2954), or core buildup including any pins (D2950), provided by an out-of-network provider on April 29, 2021.

You asked the Plan to pay for a prefabricated post and core in addition to crown or core buildup including any pins. You say that all the services that were provided were necessary. The Plan denied your request. The Plan says there is no coverage for the services that were provided.

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 prefabricated post and core in addition to crown (D2954), or core buildup including any pins (D2950), provided by an out-of-network provider on April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) debridement of
bone (11044) debridement, subcutaneous tissue (11042) provided on June 7, 2021, by an OON provider.

You asked the Plan to pay for the nursing facility care. You say that due to the enrollee's medical condition,
emergency wound care was provided by your physician in good will without requesting an authorization and in
absence of another contracted/available wound care physician. 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 must 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 (99308)
debridement of bone (11044) debridement, subcutaneous tissue (11042) provided on June 7, 2021, by an OON
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network urologist.
You asked the Plan to pre-approve the referral. You say that you do not want to continue with the in-network
provider. The Plan denied your request. The Plan says two in-network urologists have been authorized.
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 referral to an out-of-network urologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IV tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on December 1, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as 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. Both CPT code(s): S1015 and S8301 has a status code of "I". Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 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 IV tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass lenses purchased from an out-of-network provider
on May 21, 2021.
You asked the Plan to pay for eyeglass lenses. You say that this charge is not yours. The Plan denied your
request. The Plan says this is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when they are received from an in-network provider.
We looked at the file and the Plan's rules. The Plan's benefit does not cover eyeglasses from out-of-network
providers. Based on this information, we decided that the Plan's rules for coverage of eyeglass lenses have not
been met. Therefore, we decided that the Plan does not have to pay for eyeglass lenses purchased from an outof-
network provider on May 21, 2021.