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

 We decided that the Plan does not have to pay for the x-ray and transportation of portable x-ray equipment provided on March 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the x-ray and transportation of portable x-ray equipment. You say that the services were medically necessary at the skilled nursing facility where the enrollee resides. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the x-ray and transportation of portable x-ray equipment provided on March 14, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the face mask interface (A7031) rendered by the out-of-network (OON) provider on June 15, 2021.  You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the face mask interface (A7031) rendered by the out-of-network (OON) provider on  June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve spine surgery using an artificial intervertebral discs (ADR) at cervical level 4 to 5 and 6 to 7.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational. The Plan states there has been limited quality testing to prove efficacy of treatment of two contiguous levels of ADR.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found multilevel cervical ADR remains experimental. Long term outcomes studies are needed. It is not Food and Drug Administration (FDA) approved for multiple levels.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve spine surgery using an artificial intervertebral discs (ADR) at cervical level 4 to 5 and 6 to 7.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 11, 2021.  

You asked the Plan to waive the copayment for the colonoscopy. You say that if you knew the procedure would cost this much, you would not have had it done. 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 $275 copayment for outpatient hospital surgery visits.   

You have been asked to pay a $275 copayment for the colonoscopy. The record shows that the procedure was not a screening colonoscopy. A colonoscopy 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 colonoscopy provided on August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (81291, 81381) provided on April 22, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your request. The Plan says this was not 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 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 laboratory services (81291, 81381) provided on April 22, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.  You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair.  You asked the Plan to pre-approve the ultra-lightweight wheelchair. You say that the enrollee is a fall risk and requires the use of a wheelchair. The Plan denied your request. The Plan says the enrollee has a wheelchair. Medicare does not cover duplicate items.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.  The file shows that the enrollee has been renting a lightweight wheelchair. This wheelchair serves the same purpose as the ultra-lightweight wheelchair. There is no documentation supporting that the lightweight wheelchair currently being rented does not meet the enrollee's medical needs. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve RFA at left L2, L3, L4, and L5 (CPT code(s): 64636, and 64635), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's doctor's notes do not show why the enrollee needs this many levels treated at once and this procedure (radiofrequency ablation at left L2, L3, L4, and L5) is not 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 the services. Our physician reviewer found the request is for radiofrequency ablation at three joint levels and there are no documented extenuating circumstances to support an exception to the guidelines. The review has determined that the medical records provided do not meet the requirements listed in the coverage criteria. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA at left L2, L3, L4, and L5 (CPT code(s): 64636, and 64635), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) for tooth # 18, core build up (D2950) for tooth # 2, and pulp caps (D3120) for teeth # 2 and 18 provided on March 10, 2021.

You asked the Plan to pay for the dental services. You say that you were told the services would be covered. You also say that your coverage was changed without you knowing. The Plan denied your request. The Plan says 1 crown is covered per year. The Plan says that 1 core build up is covered per year. The Plan says that the frequency limits have been exceeded. The Plan also says that pulp cap is not listed as a covered service.

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 crowns and core build up are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for the crown for tooth # 2 and core build up for tooth # 18 that you received on the date of service in this case. Pulp caps are not among those covered under this benefit. Additionally, the record shows that you did not call the Plan prior to the date of service to verify your benefits. The record shows that the provider contacted the Plan, however specific benefits were not discussed. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth # 18, core build up (D2950) for tooth # 2, and pulp caps (D3120) for teeth # 2 and 18 provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) and the arthrocentesis, aspiration and/or injection of a major joint or bursa, without ultrasound guidance (20610) rendered by the out-of-network (OON) provider on July 17, 2021.  

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  

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 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 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 the office visit (99204) and the arthrocentesis, aspiration and/or injection of a major joint or bursa, without ultrasound guidance (20610) rendered by the out-of-network (OON) provider on July 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight psychotropic test provided to the enrollee on November 2, 2020.  

You asked the Plan to pay for the testing. You say that this is covered by Medicare. The Plan denied your request. The Plan says this test has not been shown to be useful, medically necessary, or appropriate.  

The Plan must follow Medicare rules. The rules say that the current evidence does not support the use of GeneSight.   

Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight psychotropic test provided to the enrollee on November 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special stain provided on July 23, 2021.  You asked the Plan to pay for the provided services. You say that the code meets coverage guidelines. The Plan denied your request. The Plan says there is insufficient information to support the special stain. The Plan must follow Medicare rules. Medicare rules say that special stains are only covered under certain medical indications.  We looked at the file and Medicare rules. The records provided do not indicate why additional testing was done. Based on this information, we decided that Medicare rules for coverage of the provided services have not been met. Therefore, we decided that the Plan does not have to pay for the special stain provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the service dog support benefit.  

You asked the Plan to pre-approve the service dog support benefit. You say that your dog is a mobility service dog that helps you work on your balance and stability and helps you to walk at a slow pace. The Plan denied your request. The Plan says you have not supplied the required supporting documentation that identifies you as the owner of the service dog and that the service dog meets the American with Disabilities Act (ADA) service dog qualifications.  

The contract with the Plan says that the Plan requires supporting documentation identifying the enrollee as the owner and qualifying under the ADA for the service dog.  

We looked at the file and the Plan's rules. The file shows that there is not supporting documentation identifying you as the owner and qualifying under the ADA for the service dog. Therefore, we decided that the Plan does not have to pre-approve the service dog support benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for nursing facility care supervision (99379) provided on April 29, 2021.  You asked the Plan to pay for care supervision. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99379 is always bundled for payment and is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that code 99379 is always bundled for payment and if it is covered, the payment for it is subsumed by the payment for the services to which it is incident.   We looked at the file and Medicare rules. This code is always bundled for payment and it not separately payable. Based on this information, we decided that Medicare rules for coverage of care supervision have not been met. Therefore, we decided that the Plan does not have to pay for nursing facility care supervision (99379) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete maxillary overdenture (D5863) provided on June 16, 2021  You asked the Plan to pay for the complete maxillary overdenture. You say that you would like to appeal the denture replacement and implants. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the complete maxillary overdenture (D5863) provided on June 16, 2021
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on February 17, 2021.  

You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like this claim to be processed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  

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 February 1, 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 ultrasound of the abdomen (76705) provided on February 17, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records show that based on your current level of function you have not had a change in function that needs daily skilled therapy services. The Plan states you also do not have any daily skilled nursing needs. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 14, 2021.  

You asked the Plan to pay for the comprehensive oral evaluation (D0150). You say that the procedure was executed twice because you moved and changed dental providers. You say that the frequency restriction should be waived, and the $50 charge should be paid. The Plan denied your request. The Plan says D0150 has a frequency limit of one procedure every three plan years.  

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, you also have a maximum benefit of one comprehensive oral evaluation every three years. The Plan paid for the comprehensive oral evaluation provided on February 27, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services provided on May 25, 2021.  

You asked the Plan to pay for the dental services. You say that you were told if your dentist didn't accept Medicare, you should submit your bill and you would get reimbursed. The Plan denied your request. The Plan says payment cannot be issued for services provided by a dentist who has opted out of Medicare.  

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, dental services provided by a dentist who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on May 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (72141, 72146, 72148) provided on May 31, 2021.  You asked the Plan to pay for imaging services. You say that the enrollee received multiple tests. The Plan denied your request. The Plan says these services are not separately payable.  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 72141 is a column II code to column I code 72142, code 72146 is a column II code to column I code 72157, and code 72148 is a column II code to column I code 72149. 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 (72141, 72146, 72148) provided on May 31, 2021.