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

 
We decided that the Plan does not have to pay for the intraoral additional periapical x-ray (D0230) and crown 
(D2740) provided on May 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not informed by the provider that your 
benefits were exhausted. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items was exhausted on the same date of service May 10, 2022, when the 
Plan paid for other services on the claim. Therefore, we decided that the Plan does not have to pay for the 
intraoral additional periapical x-ray (D0230) and crown (D2740) provided on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to switch providers and you did not 
realize this service was considered a comprehensive oral evaluation. The Plan denied your request. The Plan 
says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 1, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 25, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on July 16, 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 procedure code 97530 is not supported.

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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the occupational therapy services rendered on July 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Reblozyl (CPT code J0896).

You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The Plan denied your request. The Plan says the use of this drug/regimen is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the medication. Our physician reviewer found the review has determined that the documentation does not support that Reblozyl (CPT code J0896) is medically reasonable and necessary for the enrollee. The documentation does not support that Reblozyl (CPT code J0896) is safe and effective for the enrollee.

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl (CPT code J0896).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code G0480 billed for date of service October 1, 2021.

You asked the Plan to pay for procedure code G0480. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code G0480 is bundled into payment for code G0481.

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 G0480 is a column II code to column I code G0481. 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 procedure code G0480 billed for date of service October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified preventive procedure (D1999) provided on 
October 8, 2021. 
 
You asked the Plan to pay for a preventive procedure. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an unspecified preventive procedure (D1999) is not 
covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 an 
unspecified preventive procedure (D1999) provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 28, 2022.

You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that the enrollee's Plan allows out-of-network coverage for emergency services or when there are no in-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 did not pre-approve the services 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 provided on April 28, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 7, 2022.

You asked the Plan to pay for procedure code 76705. You say that you disagree with the denial. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.

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 76705 is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service July 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 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 provider has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4341 x3) or 
pay for the debridement procedure (D6101), and the intravenous sedation (D9243) provided by an out-of-
network provider on July 11, 2022. 
 
You asked the Plan to pay more for the periodontal scaling and root planing (D4341 x3). You say that you were 
told by the provider's office that you would need to pay the full amount up front and then you would be 
reimbursed. You say you were never told about a partial reimbursement payment. The Plan denied your 
request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your services are received from an out-of-network provider and the debridement procedure (D6101), and the 
intravenous sedation (D9243) 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 Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the periodontal scaling and root planing (D4341 x 3). This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Also, though the Plan offers a dental benefit in excess of 
Medicare coverage, the debridement procedure (D6101) and the intravenous sedation (D9243) are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay more for the 
periodontal scaling and root planing (D4341 x3) or pay for the debridement procedure (D6101), and the 
intravenous sedation (D9243) provided by an out-of-network provider on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 17, 2022.

You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 procedure code 70450 billed for date of service June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM device (K0553).

You asked the Plan to pre-approve the CGM and supplies. You say that the enrollee did a trial of the Freestyle Libre 2 for 2 weeks and this was beneficial to obtain more data to help you adjust your insulin dose. The Plan denied your request. The Plan says the records do not support that the enrollee meets all of the medically necessary criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the receiver (Monitor), dedicated, for use with therapeutic continuous glucose monitor system (K0554) and supply allowance used with a therapeutic CGM device (K0553).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554).

You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that you are appealing the denial of the Dexcom CGM. The Plan denied your request. The Plan says the enrollee does not meet all of the medical necessity criteria for the equipment requested.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown-porcelain/ceramic (D2740) tooth #19 and maxillary partial denture-case metal framework with resin denture bases (D5213).

You asked the Plan to pre-approve the dental services. You say that due to an infection, you need the requested services. The Plan denied your request. The Plan says your benefit for the requested item or service has already been exhausted and one 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. This benefit includes the requested crown-porcelain/ceramic (D2740) but is limited to one procedure per calendar year. This benefit includes only those items and services specifically listed in your Plan contract. Maxillary partial denture-case metal framework with resin denture bases (D5213) is not covered under the Plan's dental benefits.

 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested crown-porcelain/ceramic (D2740) tooth #19 was exhausted on date of service October 26, 2022. Maxillary partial denture-case metal framework with resin denture bases (D5213) is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve crown-porcelain/ceramic (D2740) tooth #19 and maxillary partial denture-case metal framework with resin denture bases (D5213).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 2, 2022.

You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.

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 76705 is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service June 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PureWick urine collection system.

You asked the Plan to pre-approve incontinence supplies. You say that not having the PureWick collection system will greatly decrease your quality of life. 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 the PureWick urine collection system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressal 0.02% solution.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says Rhopressa is a self-administered drug and does not fall under Part B coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rhopressal 0.02% solution. 

Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the resin-based composites (D2391 and D2392) provided on June 30, 2022.

You asked the Plan to fully pay for the fillings. You say that the provider you saw is not the provider listed on the letter you received. You say that you did not request any services and the provider chose the service. The Plan denied your request. The Plan says white fillings on posterior teeth will be processed as a silver filling and you are responsible for the difference between the allowed amounts.

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 Plan is only obligated to pay the cost of a silver filling on posterior teeth and you are responsible for the difference in cost. Therefore, we decided that the Plan does not have to fully pay for the resin-based composites (D2391 and D2392) provided on June 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 5, 2022.

You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 procedure code 70450 billed for date of service March 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on October 22, 2021.

You asked the Plan to pay for the x-ray. You say that the enrollee was not enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on October 15, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on October 22, 2021.