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

 We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker (CPT code 33274), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee is short of breath and may be in danger of a stroke or cardiac arrest due to the enrollee not being able to move as much as they have gained thirty (30) pounds. You state that if the enrollee does not have this procedure the enrollee could lose their life or not be able to function with their day-to-day life. The Plan denied your request. The Plan says the enrollee's records do not show that they are enrolled in a CMS approved CED study.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. In order for the requested services to be covered, the enrollee would need to have clinical notes that show they are or are going to be enrolled and participating in a CMS approved CED study. The enrollee's records do not show that they are enrolled in a CMS approved CED study. Therefore, we decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker (CPT code 33274), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical first radiographic image (D0220) provided on August 27, 2021.  You asked the Plan to pay for a limited oral evaluation and an intraoral periapical first radiographic image. You say that the appointment was the result of a piece of tooth breaking off during flossing the night before. You also say that if a piece comes off a tooth, it is something that should be addressed. You are requesting reconsideration of coverage. The Plan denied your request. The Plan says the requested services are not included on your Plan's benefit schedule, and therefore, are not 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, 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 a limited oral evaluation (D0140) and an intraoral periapical first radiographic image (D0220) provided on August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) scan of the head (70544) provided on August 30, 2021.  You asked the Plan to pay for MRA scan of the head. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate 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 70544 is a column II code to column I code 70553. 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 magnetic resonance angiography (MRA) scan of the head (70544) provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for home visit for respiratory therapy care (99503) provided on June 15, 2021.  You asked the Plan to pay for home visit for respiratory therapy care. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this code is not eligible for payment under Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99503 is home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation).  We looked at the file and Medicare rules. In this case, code 99503 has a Status Code "I" under the Physician Fee Schedule. This indicates that this code is not valid for Medicare purposes as Medicare sues another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home visit for respiratory therapy care have not been met. Therefore, we decided that the Plan does not have to pay for home visit for respiratory therapy care (99503) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 28, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you did not feel like a patient and felt dismissed. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for each specialist visit.   You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on September 28, 2021.  We note your complaint that you felt dismissed by the provider. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cast application rendered on June 8, 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 payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global
surgical package.
We looked at the file and Medicare rules. Billed procedure code 29405 (application of short leg cast) was billed
within 90 days of major surgical procedure 27822 (open treatment of ankle fracture) performed on May 27,
2021. The cast application is related to the major procedure and payment is included in the global surgical
payment. Therefore, we decided that the Plan does not have to pay for the cast application rendered on June 8,
2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 9, 2021.  You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.  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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided on September 8, 2021.  You asked the Plan to pay for a comprehensive periodontal evaluation. You say that you have gum disease and have been treated by the same provider for some number of years. You also say you would like the Plan to pay for this service. The Plan denied your request. The Plan says the service provided 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 a comprehensive periodontal evaluation (D0180) provided on September 8, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the records received show the enrollee has failed medication management. The Plan states the records also do not show the enrollee has tried and failed other modalities of treatment such as physical therapy or surgery. The Plan states they the request 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 service. Our physician reviewer found criteria for a stimulator not met. There is no documentation that all conservative measures for low back pain management have been tried including recent physical therapy (PT) for back pain.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a prostate specific antigen (PSA) test received July 30, 2021.  You asked the Plan to pay for a PSA test. You say that the PSA change was enough to warrant a second test. The Plan denied your request. The Plan says the PSA change was not enough to warrant a second test.  The Plan follows Medicare rules. Medicare rules say that generally, for patients with lower urinary tract signs or symptoms, the test is performed only once per year unless there is a change in the patient's medical condition.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a PSA test. Our reviewer says that the PSA change was not significant enough to warrant the second test. Our physician reviewer found that the claim denial of a second PSA test was appropriate. In this case, a PSA of .64 rose to1.1. The PSA values were well below the 4 ng/mL cutoff making prostate cancer extremely unlikely despite the increase.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PSA test have not been met. The record shows that the Medicare benefit limit for PSA testing was exhausted prior to the service at issue. Our reviewer says that the PSA change was not significant enough to warrant the second test.  Therefore, we decided that the Plan does not have to pay for a prostate specific antigen (PSA) test received July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on August 4, 2021.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that you would like to know why these x-rays were not covered. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.  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 series of intraoral x-rays (D0210) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 8, 2021.  You asked the Plan to pay for the periodic oral evaluation. You say that you were advised that you had ulcers in your mouth and needed to follow up with your dentist. You also say that you feel that this evaluation was medically necessary, and the dentist wrote two prescriptions for the condition. The Plan denied your request. The Plan says this procedure is only covered once every 6 months.  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, oral exams are limited to once every 6 months. The record shows that you received a periodic oral evaluation (D0120) on July 29, 2021 and your oral exams benefit had been exhausted for the 6-month time period. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that you want to see an out-of-network provider who is a family friend and understands your issues. The Plan denied your request. The Plan says there are in-network providers that can provide the requested services.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visits to be provided by an out-of-network provider.
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 their records show that you have entered into hospice care. The Plan states that Medicare rules say that once you enter into hospice care, all of your medical benefits are covered by original Medicare. The Plan states if you have optional dental or vision coverage as part of your benefit selection with this health plan, they will continue to cover these benefits.  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 16, 2022. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 prior to the Huntington's diagnosis, you were independent. You state the goal is to transition to independent living as you remain motivated and optimistic. The Plan denied your request. The Plan says your records do not show that you have skilled rehabilitation or nursing needs that can only be provided on a daily basis in a SNF. The Plan states the services you require (rehabilitation) 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 states you may discuss the best option with your provider.  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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a prolonged evaluation and management service (99358) provided on August 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a prolonged evaluation and management service. You say that this provider was requested to see the patient as an attending provider in an outpatient capacity. You also say there is a medical necessity pre-established with the patient and the facility for the provider to provide services to the patients needing care. The Plan denied your request. The Plan says this is a non-contracted provider who performed services to the member without prior authorization from the Plan.  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 a prolonged evaluation and management service (99358) provided on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lab services (81479) provided  You asked the Plan to pre-approve the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies all genetic cardiovascular risk assessment panels, except for the basic lipid panel for patients with documented cardiovascular disease.  We looked at the file and Medicare rules. The service is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pre-approve lab services (81479) provided
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tendon excision (25109) provided on March 3, 2021.  You asked the Plan to pay for the tendon excision (25109). You say that supporting documentation is attached to support the billed charges. You say that documentation should be reviewed and reprocessed for payment. The Plan denied your request. The Plan says the service 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 25109 is excision of tendon, forearm and/or wrist, flexor or extensor, each.    We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the tendon excision (25109). Our reviewer says that the documentation was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not document an excision of tendon forearm and/or wrist flexor or tendon and the report does not support the coding of CPT 25109 per the Policy Manual.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tendon excision (25109) have not been met. Therefore, we decided that the Plan does not have to pay for the tendon excision (25109) provided on March 3, 2021.