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

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
services coded 95940 provided on October 15, 2020.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring 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 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 95940
for the continuous intraoperative neurophysiology monitoring services is a column II code to column I code
95813. 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 the continuous intraoperative neurophysiology monitoring services coded 95940 provided on October
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy evaluation (97163) provided May 13, 2020.
You asked the Plan to pay for Physical therapy evaluation. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the code is not appropriate for the service billed
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 97163 is physical therapy evaluation, high complexity. We find that CPT code 97163 is not supported in the medical record. Specifically, there is a more appropriate
Healthcare common procedure coding system code (G0151) for the billed service. Based on this information, we decided that Medicare rules for coverage of Physical therapy evaluation have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy evaluation (97163) provided May 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy of the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to pay more for the core buildup, including any pins when required (D2950) and endodontic therapy (D3330) provided on August 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the problem focused limited oral evaluation or pay more for the core buildup and endodontic therapy. You say that you would like these services to be reconsidered for payment. The Plan denied your request. The Plan says the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that the total $1,111 amount applied correctly for as your liability for the core buildup and endodontic therapy.

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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 9, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. You are also responsible for a 50% coinsurance for the core buildup and endodontic therapy, plus the difference between the billed amount and allowed amount for the services being received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and to pay more for the core buildup, including any pins when required (D2950) and endodontic therapy (D3330) provided on August 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visual field assessment with concurrent real time data analysis (ForeSee Home Device).

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device is not covered by Medicare, as it a precautionary-type equipment.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you have nonexudative macular degeneration. The record provided indicates that you are use an Amsler grid. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve visual field assessment with concurrent real time data analysis (ForeSee Home Device).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist assistant on December 22, 2019.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist assistant on December 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on September 1, 2021.

You asked the Plan to pay for the dental services. You say that you were not aware that the dentist was out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that you pay 100% of the cost for dental services received out of network.

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 the services are listed as covered, dental services performed by a dentist that is out of network are not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on September 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist assistant on January 7, 2020.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a physician. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist assistant on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided May 18, 2021 to May 23, 2021.

You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation provided does not support the diagnosis code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that diagnosis code I21.A1 is not supported in the medical record. Specifically, during the course of this hospital admission, a diagnosis of myocardial infarction type 2 was not documented, and no treatment plan or care for this diagnosis was documented. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided May 18, 2021 to May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had on August 24, 2021.

You asked the Plan to waive the copayment for the primary care office visit. You say that had you known the doctor you saw was not a Patient Centered Medical Home (PCMH) provider, you would have gone to another doctor. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for services provided by a non-PCMH provider. 

You have been asked to pay a $35 copayment for the primary care office visit. The Plan has confirmed that the doctor you saw is not a PCMH provider. That is why the copayment applies. 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 primary care office visit you had on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical access to an implant body (D6011 x 4), and free soft tissue procedure (D4277 x 4).

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says implant related services are not covered. The Plan also says that dental services to be performed by a dentist other than your assigned dentist are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage and free soft tissue procedure is listed as covered, dental services to be performed by a dentist other than your assigned dentist are not among those covered under this benefit. Additionally, surgical access to an implant body is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical access to an implant body (D6011 x 4), and free soft tissue procedure (D4277 x 4).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from July 4, 2021,
through July 17, 2021.

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says
continuation of SNF services provided from July 4, 2021, through July 17, 2021 are not medically necessary.

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 pay for continuation of SNF services. Our reviewer
says that daily skilled services are not medically necessary. Our physician reviewer found that based on the
medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the
specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and
effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy
services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely
and effectively provide medically necessary and reasonable treatment. Based on the medical records provided
daily skilled services were not required. As a practical matter, this enrollee did not require the services on an
inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this
case from July 4, 2021, through July 17, 2021.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the
Plan does not have to pay for continuation of SNF services provided from July 4, 2021, through July 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on September 17, 2021.
You asked the Plan to pay for the dental service. You say that you were sent to an oral surgeon by your dentist. You say that most oral surgeons were scheduling a month out. You say that you could not wait that long. You say that your dentist found an oral surgeon available. You say that you were advised by a plan representative that the service would be covered. You also say that this was an emergency. The Plan denied your request. The Plan says bone replacement graft is 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 bone replacement graft is not among those covered under this benefit. Additionally, the record shows that the Plan only advised that an extraction would be covered. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5224) and a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) provided on April 26, 2021.

We decided that the Plan does not have to pay for an immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5224) and a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) provided on April 26, 2021.

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. 

We looked at the file and Medicare rules. The EOC confirms that an immediate mandibular partial denture is not listed as a covered benefit. The EOC also confirms that you pay 50% of the portion of the covered charges for endodontic, periodontic, and oral surgery dental services. The records show that you have exhausted your $500 allowance for covered comprehensive dental services prior to this date of service. The records also show that at the time this claim was processed, you had $577 remaining of the $2,000 benefit maximum allowed. The allowed amount of the claim was $1,174.50, resulting in a 50% coinsurance obligation of $587.25. The Plan paid $577, which left a balance of $10.25 which was added to your total responsibility ($587.25 + $10.25 = 597.50). Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for an immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5224) and a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for grab bars for a shower provided on February 17, 2021.

You asked the Plan to pay for grab bars. You say that the items at issue are a medical necessity for you. The Plan denied your request. The Plan says the items at issue are not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for grab bars for a shower provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided out of network on June 22, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 physician services provided out of network on June 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 10, 2021.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 10, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided June 17, 2021.

You asked the Plan to pay for therapeutic activities. You say that you would greatly appreciate consideration to
honor the enrollee's in-network benefits as a courtesy to the enrollee. Please review all attached documentation
supporting this request and process the claim for payment. The Plan denied your request. The Plan says this
code is not appropriate for the service billed.

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 by the provider (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, there is a more appropriate
Healthcare Common Procedure Coding System code (G0158) for the billed service. Based on this information,
we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided
that the Plan does not have to pay for therapeutic activities (97530) provided June 17, 2021.