Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on June 25, 2021.
You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the claim should be reprocessed. The Plan denied your request. The Plan says procedure code 97010 is a bundled code and is 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, the CPT Code Manual definition of code 97010 is application of a modality to 1 or more areas; hot or cold packs.
We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on June 25, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found IRF admission is not medically necessary based on lack of current medical complexity and lack of skilled nursing needs. Your rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a crown (D2740) for tooth # 8 provided on February 1, 2021.

You asked the Plan to pay for the crown. You say that your provider advised that decay was present under your existing crown on tooth # 8. You say that your provider advised it was necessary to remove the crown and all carious tissue was removed. The Plan denied your request. The Plan says that the crown is not medically necessary.

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. The Plan covers the crown when the services are medically necessary and reasonable.

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 the crown. Our reviewer says that the crown is medically necessary. Our physician reviewer found the provided x-ray does show a radiolucent area under the old crown and it does appear that the crown would be in need of replacement. The reviewer found that the provider statement indicated that decay was found, and the crown was replaced for the enrollee the same day. The reviewer found that given the provider statement and the radiolucent region seen on the provided x-ray, the crown was in need of replacement with no other reasonable alternative treatment, and it was medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Specifically, there was radiolucent area under the old crown which needed replacement. Therefore, we decided that the Plan has to pay for a crown (D2740) for tooth # 8 provided on February 1, 2021.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88312) rendered by the out-of-network (OON) provider on January 25, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88312) rendered by the out-of-network (OON) provider on January 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 23, 2021.

You asked the Plan to pay for 70450. 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 codes 70450 and 70496 have a procedure-to-procedure edit modifier of 1 which means modifiers are allowed for this code pair; however, an appropriate modifier was not billed with this code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which has not been billed with this code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 10,
2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you were not aware you
needed a referral to see this provider and you would like to continue to see this provider. 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 psychiatric diagnostic evaluation provided on June 10, 2021
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, problem focused (D0140) and
clinical crown lengthening - hard tissue (D4249) provided April 29, 2021.
You asked the Plan to pay for the limited oral exam and clinical crown lengthening. You say that the services
were provided for an emergency and should be covered. The Plan denied your request. The Plan says you have
exceeded frequency limits for the exam and crown lengthening is not a covered service under your benefits.
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. The Plan covers the limited
oral exam once per plan year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam
was previously covered on January 20, 2021. Based on this information, we decided that the Plan's frequency
limit for coverage of the limited oral exam has been exceeded. Though the Plan offers dental benefits in excess
of Medicare coverage, the clinical crown lengthening is not among those covered services. Therefore, we
decided that the Plan does not have to pay for the limited oral evaluation, problem focused (D0140) and clinical
crown lengthening - hard tissue (D4249) provided April 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile X-Ray services provided on April 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for mobile X-Ray. You say that these services do not require authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with 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 mobile X-Ray services provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 26, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 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 laboratory services provided on May 26, 2021
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for osteotomy of the tibia (27705) provided on April 19, 2021.
You asked the Plan to pay for 27705. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because a procedure-to-procedure (PTP) edit exists between codes 27705 and 28725 so code 27705 would be considered inclusive to code 28725.
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 27705 does not have a bundled relationship with code 28725. This code can be paid as a separate line item. The Plan has attested that code 27705 is described in the operative report. The Plan has not provided another basis to support a denial of payment for this code. Based on the claim submitted, Medicare billing criteria have been met. Therefore, we decided that the Plan has to pay for osteotomy of the tibia (27705) provided on April 19, 2021.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the laboratory service represented by code 85045 provided on April 15, 2021.

You asked the Plan to pay for code 85045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

The enrollee was referred for code 85045 by a contract provider. The file does not show that the plan provided notice that code 85045 would not be covered. Under Medicare rules, this means code 85045 is considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory service represented by code 85045 provided on April 15, 2021.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint.
You asked the Plan to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect
visualization), with image guidance, includes obtaining bone graft when performed, and placement of
transfixing device (27279). You say that the sacroiliac (SI) joint fusion is medically necessary as a last resort to
resolve the enrollee's SI joint pain. The Plan denied your request. The Plan says there are not enough studies to
show that fusion would be safe and effective for the enrollee.
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 arthrodesis, sacroiliac joint,
percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft
when performed, and placement of transfixing device (27279). Our reviewer says that the requested
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the requested SI joint arthrodesis is not supported. Medicare local coverage determination indicates that
there needs to be a minimum of 6 months of intensive non-operative treatment that must include medication
optimization, activity modification, bracing, and active therapeutic exercises. In this case, the enrollee
underwent lumbar fusion surgery in April 2021 and returned 6 weeks later for an evaluation. The enrollee
complained of sacroiliac joint pain. A diagnostic injection provided a reduction in pain complaints. However,
there was no documentation of at least 6 months of intensive non-operative treatment to the sacroiliac joint
prior to this request. There is no compelling rationale presented or extenuating circumstances noted to support
the medical necessity of this request as an exception to the guidelines. Therefore, the requested arthrodesis
sacroiliac joint injection is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect
visualization), with image guidance, includes obtaining bone graft when performed, and placement of
transfixing device (27279) have not been met. Therefore, we decided that the Plan does not have to pre-approve
arthrodesis, sacroiliac joint
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the federally qualified health center (fqhc) visit coded G0467, the office visit coded 99213, and the collection of venous blood by venipuncture coded 36415 provided on June 23, 2020.

You asked the Plan to pay for the federally qualified health center (fqhc) visit, the office visit, and the collection of venous blood by venipuncture. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable
.
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. The documentation shows that code G0467 was denied to due unbundling/fragmentation and codes 99213 and 36415 were denied due to the payment for this service is included in the fee for the procedure. However, no documentation was shown to support what the procedure was that payment was included in. The documentation does not include supporting details on why this entire claim was denied. The file shows limited documentation to support the Plan's denial. Therefore, we decided that the Plan has to pay for the federally qualified health center (fqhc) visit coded G0467, the office visit coded 99213, and the collection of venous blood by venipuncture coded 36415 provided on June 23, 2020.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on May 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary, and you were not aware that the facility failed to get 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on May 7, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 11, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a nursing facility, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic substrate (D2740) and core buildup, including any pins (D2950) provided May 11, 2021.

You asked the Plan to pay for the crown and core buildup. You say that you checked prior to the services to ensure the dental office was in-network. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 crown - porcelain/ceramic substrate (D2740) and core buildup, including any pins (D2950) provided May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal mouth guard (D9944) provided on June 8, 2021.

You asked the Plan to pay for the dental item. You say that you need this mouth guard as a preventive measure. You say your previous insurance covered this. You say that you are disappointed with your current insurance. You also say that you could not check your coverage online. The Plan denied your request. The Plan says the occlusal mouth guard is not a covered dental item.

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 occlusal mouth guard is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal mouth guard (D9944) provided on June 8, 2021.

Your complaint about not being able to access your coverage online is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.