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

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided
to the enrollee on August 2, 2021.
You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid
for. The Plan denied your request. The Plan says the records are insufficient to support payment for the
services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient.
In addition, the procedure report should clearly document the indications and the medical necessity for the
blocks along with the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on August 2, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has stabilized medically. Although the enrollee does not have any skilled nursing needs, she has had a significant decline in physical functioning. The enrollee does require skilled therapy services on a daily basis at a skilled nursing facility to restore function and avoid further decline or complications. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluoride varnish (D1206), retainer crowns (D6740) for teeth # 3 and 5, porcelain pontic (D6245) for tooth # 4, and core build up (D2950) for tooth # 3, and a porcelain crown (D2740) for tooth # 3.

You asked the Plan to pre-approve the dental services. You say that you have a broken crown with very sharp edges. You say that you cannot eat on the right side. You also say that this is an emergency situation and should be approved. The Plan denied your request. The Plan says the services are not covered by Medicare.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve fluoride varnish (D1206), retainer crowns (D6740) for teeth # 3 and 5, porcelain pontic (D6245) for tooth # 4, and core build up (D2950) for tooth # 3, and a porcelain crown (D2740) for tooth # 3.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a shoulder arthroscopy procedure performed on July 15, 2021.
You asked the Plan to waive the deductible and copayment for the shoulder arthroscopy. You say that you did not have this much of a copayment after your first surgery. The Plan denied your request. The Plan says the correct amount was applied to your deductible and the correct copayment was also applied.
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 $1000 deductible which applies to certain items and services.
Your contract with the Plan also clearly says that you must pay a $325 copayment for surgery at an outpatient hospital after the deductible is met. The item or service you asked the Plan to waive the deductible and copayment for falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1000 deductible which applies to certain items and services. This cost sharing is a contractual obligation that was met during the time the shoulder arthroscopy was received on July 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible and copayment for a shoulder arthroscopy procedure performed on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the surgical extraction (D7210) and bone
replacement graft (D7953) provided on October 23, 2021.
You asked the Plan to reimburse you for the dental services. You say that you got laid off from your job. You
say that your wife had to quit her job to take care of your son. You say that you need this money. The Plan
denied your request. The Plan says the extraction and bone replacement graft are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the extraction and bone replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the surgical extraction (D7210) and bone replacement graft (D7953) provided on October 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).

You asked the Plan to pre-approve the dental item. You say that your top denture was thrown away at the hospital. You also say that you need a new one. The Plan denied your request. The Plan says 1 complete upper denture is covered every 5 plan years. The Plan also says that the frequency limit has been reached.

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 and complete upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture that you received on April 16, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a trigger point injection provided on September 3, 2021.
You asked the Plan to waive the copayment for the injection. You say that you did not have surgery and you should only owe the specialist copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $350 copayment for surgical procedures at an outpatient hospital facility. You have been asked to pay $284.33, which is less than the $350 copayment for the injection. The injection is considered a surgical procedure and falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a trigger point injection provided on September 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for interpretation of a computed tomography (CT) scan of the pelvis provided on September 9, 2021, billed with 72193.
You asked the Plan to pay for the CT scan interpretation as billed. You say that this should be paid. The Plan denied your request. The Plan says the Column 2 code was not billed with a required 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 72193 is a column II code to column I code 74160 from the same billing provider on this date of service. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for interpretation of a computed tomography (CT) scan of the pelvis provided on September 9, 2021, billed with 72193.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mounted scooter carrier (A9270).
You asked the Plan to pre-approve a mounted scooter carrier. You say that you need this because your husband is having problems from transferring you to the vehicle. The Plan denied your request. The Plan says this is not covered.
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 mounted scooter carrier (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) for the enrollee.
You asked the Plan to pre-approve a power seat elevation system (E2300). You say that a power seat elevation system is medically necessary for the enrollee. The Plan denied your request. The Plan says a power seat elevation system is not covered by Medicare.
The Plan must follow Medicare rules. The rules state a power seat elevation system is statutorily excluded from coverage for all indications. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with several accessories to include a power seat elevation system (E2300) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implant placement (D6010 x 2), implant supported crowns (D6065 x 2), and prefabricated abutments (D6056 x 2).
You asked the Plan to pre-approve the dental services. You say that the enrollee has loose teeth that need to be pulled. You also say that the enrollee does not want to wear prosthetic dentures due to an allergy. The Plan denied your request. The Plan says dental implants and all related services are not covered.
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 implants and related services for teeth # 4 and 13 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010 x 2), implant supported crowns (D6065 x 2), and prefabricated abutments (D6056 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on February 9, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the periodontal maintenance. You say that your office was advised to opt out of Medicare because you had absolutely no interaction with Medicare at all since the practice started in 2007. The Plan denied your request. The Plan says the treating provider has opted out of Original Medicare participation. The Plan also says that no payment can be made for services rendered by an opt out provider.
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 periodontal maintenance (D4910) provided on February 9, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation 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 the records do not show that the method to be used is thermal and non-pulsed.

The Plan must follow Medicare rules. Medicare rules says that only thermal forms of radiofrequency ablation
are covered.

The cooled form of radiofrequency ablation is not thermal and is not covered. 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 cooled radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies coded as A4520.

You asked the Plan to pre-approve incontinence supplies. You say that you feel this should be covered because you have a letter from the doctor showing it is a necessity. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies coded as A4520.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient admission does not meet Medicare guidelines.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient coverage are met in this case. Our physician reviewer found The review that the record showed that at the time of the inpatient admission that the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient hospital care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Quad Push button and wheelchair transport brackets (K0108).

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 support for these requests.

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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Quad Push button and wheelchair transport brackets (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two bone replacement grafts for ridge preservation (D7953 x2).
You asked the Plan to pre-approve the bone replacement grafts. You say that you need this service in order to receive an implant. The Plan denied your request. The Plan says this service is not covered under 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, 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 two bone replacement grafts for ridge preservation (D7953 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 9, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a panel constitutes a single procedural service, so one CPT code must be submitted for the panel.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on January 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inversion table (any type).
You asked the Plan to pre-approve an inversion table. You say that an inversion table is medically necessary. The Plan denied your request. The Plan says an inversion table is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. An inversion table does not serve a purpose that is primarily medical in nature. This item is available to the public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an inversion table (any type).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management services (99490) provided on September 30, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for chronic care management services. You say that the referring provider requested this provider be called in to see the patient as an attending provider in an outpatient capacity. You also say that there is a medical necessity pre-established with the patient and the facility for this provider to provide services to the patients needing care. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 chronic care management services (99490) provided on September 30, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 24,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says an appropriate modifier was not billed in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for imaging services provided to the enrollee on September 24,
2021.