Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on January 26, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 office visit (99213) provided on January 26, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99291, 93010) provided March 1, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. 

We find that CPT code 99291, & 93010 is not supported in the medical record. Specifically, the date of service on the records does not match the date of service on the claim submitted.

Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99291, 93010) provided March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on April
12, 2021.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you have gotten this shot
before with zero copayment. The Plan denied your request. The Plan says you were charged this coinsurance
correctly. The Plan says that you may not have paid cost sharing before because on other dates of service, the
Prolia injection was billed in conjunction with an office visit copayment.
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 10%
coinsurance for Medicare Part B drugs that are not billed in conjunction with an office visit copayment. No
coinsurance is owed if the drug is billed in conjunction with an office visit copayment.
You have been asked to pay 10% coinsurance for the Prolia injection. The billing records show that on the
April 12, 2021, there was no office visit copayment billed in conjunction with the injection. That is why the
coinsurance applies in this case and may not have applied to other dates of service. 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 coinsurance for the Prolia injection you received on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from March 24, 2020, to March 27, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the inpatient services were reported with an incorrect DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with G93.41, metabolic encephalopathy. 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 services provided. Our physician reviewer found that the documentation indicates the support of diagnosis related group (DRG) 683. There was a primary diagnosis code assignment of N17.9, acute kidney failure unspecified, and a secondary diagnosis code of G93.41, metabolic encephalopathy, that were reported by the hospital. The primary diagnosis code, N17.9, is supported. However, the review has determined that the billed DRG 682 is not supported in the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from March 24, 2020, to March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair and accessories. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) or pay more for the periodic oral evaluation (D0120) provided on May 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the preventive procedure and to pay more for the periodic oral evaluation. You say that you believe that the cost share amount you were charged is unacceptable. You also say that you would like to be reimbursed in full for these services. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit under your dental plan. The Plan also says that the liability amount was applied correctly, and that cost sharing is a contractual obligation under the Plan and cannot be waived.

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 unspecified preventive procedure (D1999) is not among those covered under this benefit. You are also responsible for the difference between the billed amount and allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) or pay more for the periodic oral evaluation (D0120) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 1, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that the issue was that a filling came out and needed to be replaced. You also say that this was an unexpected issue, and you had no choice but to get it replaced. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.

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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 27, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial denture
(D5214).
You asked the Plan to pre-approve a complete upper denture and a partial denture. You say that you would like
the Plan to reconsider their denial. The Plan denied your request. The Plan says you are covered for complete
and partial dentures once every five plan years. The Plan says that you received these dentures in April of 2019,
which is less than 5 years ago.
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 complete and partial
dentures with codes D5110 and D5214 are covered once every five plan years. The file shows that you received
these dentures on April 19, 2019, which is less than five years ago. Therefore, we decided that the Plan does
not have to pre-approve a complete upper denture (D5110) and a partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve ventilator. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the ventilator settings ordered could alternatively be provided by a bi-level positive airway pressure (BiPAP) device with average volume assured pressure support (AVAPS).

The Plan must follow Medicare rules. Medicare rules say that Medicare policy precludes coverage for a ventilator device used to deliver continuous and/or intermittent positive airway pressure. 

We looked at the file and Medicare rules. This ventilator is being requested for BiPAP therapy with backup AVAPS mode, for which a ventilator may not be covered. Based on this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
You asked the Plan to pre-approve an MRI. The Plan denied your request. The Plan says the enrollee has not
tried and failed conservative treatment for at least six weeks.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve an MRI. Our physician reviewer found
that the enrollee has chronic low back pain, spinal stenosis. She had only 1 or 2 sessions of physical therapy
(PT) and did not return. She reported radiating pain to the legs and buttocks and is limited with walking due to
fatigue. There was tenderness in the lumbar paraspinal muscles, positive facet loading, normal gait, positive
straight leg raises, normal strength and sensation, and normal reflexes. Based on the enrollee not having
exhausted PT or other conservative treatments, and without documented evidence of a red flag diagnosis to
justify earlier consideration of imaging, this request for MRI lumbar spine will be considered not medically
necessary based on the notes provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), intraoral periapical x-rays (D0220 and D0230), pulp vitality tests (D0460), preventive procedure (D1999), and endodontic therapy (D3320) provided on February 10, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, pulp vitality tests, preventive procedure, and endodontic therapy. You say that you never received a denial notice for this claim. You also say that you have never had issues with paying for services and then sending them in for a claim. The Plan denied your request. The Plan says you received these services from a provider who has chosen not to receive Medicare funds. The Plan also says that you did not contact the Plan prior to receiving these services regarding your cost share or provider questions.

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 by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), intraoral periapical x-rays (D0220 and D0230), pulp vitality tests (D0460), preventive procedure (D1999), and endodontic therapy (D3320) provided on February 10, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator, any type (L8679) percutaneous implantation of neurostimulator electrode array (64555).
You asked the Plan to pre-approve implanted pulse generator. You say that the neurostimulator will aid in the ability to participate in normal activities of daily living and increase blood flow to the affected areas resulting in a reduction of pain. The Plan denied your request. The Plan says the requested service is not covered by Medicare.
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. Based on this information, we decided that Medicare rules for coverage of implanted pulse generator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable neurostimulator, pulse generator, any type (L8679) percutaneous implantation of neurostimulator electrode array (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whirlpool tub.
You asked the Plan to pre-approve the tub. You say that The Plan denied your request. The Plan says the clinical information did not show that you are homebound.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. There is no evidence in the case file that you are homebound. Without this information, the tub is considered not primarily medical in nature, and not covered. Therefore, we decided that the Plan does not have to pre-approve a whirlpool tub.
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 7, 2021.
You asked the Plan to pay for the service. You say that the place of service is corrected because the service was
rendered during the enrollee's admission from June 4, 2021, through June 12, 2021. The Plan denied your
request. The Plan says the provider did not bill as required by Medicare coding regulations. The Plan states per
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements,
Section 50.6 -Physician Fee Schedule Payment Policy Indicator File Record Layout: Professional Component
(PC)/Technical Component (TC) Indicator 3 = Technical component only codes: The Plan states this indicator
identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected
diagnostic tests for which there is an associated code that describes the professional component of the
diagnostic-only tests. It also identifies codes that are covered only as diagnostic tests and therefore, do not have
a related professional code. The Plan states total RVUs for technical component only codes include values for
practice expense and malpractice expense only.
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 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the repeat facet joint injections.

You asked the Plan to pre-approve the repeat injections. You say that you would like reconsideration because the member meets criteria to move forward with the additional injections. The Plan denied your request. The Plan says the record shows that the member experienced no relief from the initial injections.

The Plan follows Medicare rules. Medicare rules say that thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet 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 repeat injections. Our reviewer says that there is no documentation of a second diagnostic MBB or the percentage of relief documented from the first MBB. There is a request for bilateral RFA when documentation only supports a prior left sided MBB. Our physician reviewer found the provider is requesting coverage for a bilateral RFA procedure when there is only documentation of one MBB performed on the left side L4-L5 and L5-S1. 

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 repeat injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the repeat facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93380) provided June 8, 2021.
You asked the Plan to pay for the duplex scan of extracranial arteries. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.
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 93380 has a bundled relationship with code 76536 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 duplex scan of extracranial arteries (93380) provided June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 5, 6, 7, and 16, and pontics (D6241) for teeth # 8, 9, 10, 11, 12, 13, 14, and 15.

You asked the Plan to pre-approve the fixed bridge. You say that you need these services. The Plan denied your request. The Plan says fixed bridge is not a covered 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 fixed bridge is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 5, 6, 7, and 16, and pontics (D6241) for teeth # 8, 9, 10, 11, 12, 13, 14, and 15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical condition bracelet.
You asked the Plan to pre-approve the requested services. You say that the enrollee will need a medical condition bracelet to notify others of his medical condition. The Plan denied your request. The Plan says the system is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a medical condition bracelet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement.
You asked the Plan to pre-approve the surgical implant placement. You say that tooth #9 has severe mobility
and tissue inflammation that is creating trauma in the area. You say that healing infection has created these
additional problems and you are seeking approval for the extraction and implant placement. The Plan denied
your request. The Plan says the extraction was approved, and the implant remains denied as a non-covered
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 the
surgical implant placement.