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

We decided that the Plan does not have to pay for the domiciliary visit provided on April 8, 2021, by an OON
provider.

You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and you
did not know that the facility failed to get a prior authorization. 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. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the domiciliary visit provided on April 8, 2021, by an OON
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the cone beam computed tomography (CT) capture with interpretation (D0364) and the retreatment of previous root canal therapy (D3348) provided on January 5, 2021.

You asked the Plan to reimburse you for the dental services. You say that you were advised by a plan representative in December 2020 that root canals were covered. You say that you were advised on the date of service that root canals were not covered at all. You also say that the date of service in this case was the first available appointment and therefore the services should be covered. The Plan denied your request. The Plan says cone beam CT is not listed as a covered service. The Plan says that retreatment of a root canal is not listed as a covered service either.

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 cone beam CT and retreatment of a root canal are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the cone beam computed tomography (CT) capture with interpretation (D0364) and the retreatment of previous root canal therapy (D3348) provided on January 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 5, 2019 to August 29, 2019.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was missing required home health data. Appropriate G or Q codes for the billed dates of service were not submitted on the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 5, 2019 to August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on February 24, 2020.

You asked the Plan to pay for foot orthotics. You say that you were told orthotics would be covered. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on February 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429, A0425) provided from February 8, 2021, to March 15, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a fixed income and cannot afford these copayments. The Plan denied your request. The Plan says the copayments were applied correctly.
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 $150 copayment for ambulance services. You have been asked to pay a $150 copayment for each of the four ambulance transportation services. 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 the emergency ambulance transportation services (A0429, A0425) provided from February 8, 2021, to March 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional occupational therapy visits.
You asked the Plan to pre-approve additional occupational therapy visits. You say that the patient is making
good gains with occupational therapy but remains below baseline. You say that the patient would benefit from
occupational therapy to maximize independence at home and improve quality of life. The Plan denied your
request. The Plan says there were sufficient skilled therapy sessions to allow transition to a home exercise
program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional occupational therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had prior therapy and
has been instructed in a home exercise program. Our reviewer says that the unique skills of a professional
therapist are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional occupational therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient visit provided on May 6, 2021.
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim processed correctly.
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 99204 is office or other outpatient visit for the evaluation
and management of a new patient. We find that the enrollee received professional services within the previous
3 years. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore,
we decided that the Plan does not have to pay for the new patient visit provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the bio choice hereditary cardio screen provided on January
21, 2021.
You asked the Plan to pay for the bio choice hereditary cardio screen. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered
benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The bio choice hereditary cardio screen test at issue in this appeal was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not
have to pay for the bio choice hereditary cardio screen provided on January 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials (99072) provided from February 17, 2021, through March 18, 2021.

You asked the Plan to pay for the additional supplies and materials (99072). You say that the daily notes show what kind of precautions were taken by the provider prior to treating the patient. You say that the medical records fully support billing code 99072 and the code should be reprocessed for payment. The Plan denied your request. The Plan says this is a bundled code and is not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, 99072 is a bundled code that is not eligible for separate reimbursement. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials (99072) provided from February 17, 2021, through March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 3, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service is medically necessary. 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 3, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips (A0100).

You asked the Plan to pre-approve additional transportation trips. You say that you have appointments
scheduled that you need to get to, and you are not able to get there yourself. The Plan denied your request. The
Plan says you have utilized the maximum number of transportation trips allowed per year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 20 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional transportation trips (A0100).
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve home health services, for the enrollee.

You asked the Plan to pre-approve the home health services. You say that the enrollee is wanting the services covered. The Plan denied your request. The Plan says that this provider is not in the enrollee's network.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. No in-network home health agencies were offered and there is no evidence that the Plan made a good faith attempt to coordinate care for the enrollee to ensure that Medicare-covered services were made available to the enrollee through its network providers. 

We requested more information to ascertain whether the enrollee was able to procure home health services from either the requested out-of-network provider or a network provider and the Plan declined to respond to this request for information. Therefore, we decided that the Plan has to pre-approve home health services, for the enrollee.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-rays (71045) and CT angiography of the chest (71275) provided from January 23, 2021, to January 28, 2021.
You asked the Plan to pay for the chest x-rays and CT angiography of the chest. You say that when you looked up hospice information on the Medicare website for the enrollee, these dates of service are not covered. 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 January 19, 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-rays (71045) and CT angiography of the chest (71275) provided from January 23, 2021, to January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the core buildup, including any pins when required (D2950) provided on May 17, 2021.
You asked the Plan to pay more for the core buildup. You say that this dental procedure was required in partial fulfillment for subsequent performance of autologous cell transplant. The Plan denied your request. The Plan says the enrollee's annual allowance has been exhausted.
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 enrollee is responsible for a 50%
coinsurance for a core buildup, including any pins when required (D2950). The contract says that the Plan offers a $1,000 annual dental benefit maximum, less the cost-sharing the enrollee pays. The contract says that after the enrollee's annual maximum benefit maximum has been met, the enrollee is responsible for the full charges of any additional dental services. The record shows that the enrollee met the annual maximum benefit while processing this claim for the May 17, 2021 date of service and the enrollee's annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the core buildup, including any pins when required (D2950) provided on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp.
You asked the Plan to pre-approve a wheelchair ramp. You say that this device is necessary to get in and out of the house. The Plan denied your request. The Plan says this 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. 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 wheelchair ramp.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive services (D1999) provided on April 21, 2021.
You asked the Plan to pay for the dental service. You say that you went for a follow up visit. You say that you have 2 free visits per year. You also say that you should not be charged for this claim. The Plan denied your request. The Plan says unspecified preventive service is not listed as a covered service. The Plan says that both you and your provider were advised prior to the date of service that your benefits are code specific. The Plan also says that the claim was processed correctly.
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 service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive services (D1999) provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 14, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that the hygienist assured you that the panoramic x-ray would be covered. The Plan denied your request. The Plan says this procedure is not covered under your dental plan. The Plan also says that the Plan contacted the provider's office and were told that you were not advised that this service would be 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 items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the total arthroplasty services provided on March 1, 2021.
You asked the Plan to pay for the total arthroplasty services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code 27130 is arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. We find that CPT code 27130 is not supported in the medical record. Specifically, these services were billed by a taxonomy code that is for a registered nurse orthopedic. Payment is not allowed by "ALL" professionals to directly submit charges for the services that they provide. Instead, the covered service of those providers are reimbursed indirectly (when in facilities) through the payment methodology for the facilities charges (for example, the Inpatient Prospective Payment System). The taxonomy code provided is not found within the Medicare Provider Supplier to Healthcare Provider Taxonomy Crosswalk. This means that the provider is not eligible for enrollment with Medicare and payment cannot be made for these services. Based on this information, we decided that Medicare rules for coverage of the total arthroplasty services have not been met. Therefore, we decided that the Plan does not have to pay for the total arthroplasty services provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (0275T).
You asked the Plan to pre-approve percutaneous laminotomy/laminectomy. You say that this request is medically necessary. The Plan denied your request. The Plan says this procedure is only covered when the enrollee is enrolled in a clinical study.
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 percutaneous laminotomy/laminectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found percutaneous laminotomy surgery is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous laminotomy/laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs these items. 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.