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

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on June 22, 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 domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by physical therapy
assistant on December 13, 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 if 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 code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.
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, and not a licensed therapist. As such, PTA 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 physical therapy assistant on December 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve biopsy, breast, with placement of breast localization device(s) (CPT code 19081) to performed at an out-of-network provider.

You asked the Plan to pre-approve the out-of-network service. You say that the service is necessary. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.

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 biopsy, breast, with placement of breast localization device(s) (CPT code 19081) to performed at an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76775) provided on July 8, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you only needed to pay for the office visit, and you were not told the ultrasound would also require a copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 $175 copayment for Medicare-covered radiological diagnostic services other than x-rays. Providers may ask you for more than one cost share payment if you get more than one service at an appointment.

You have been asked to pay a $58.18 copayment for the ultrasound. The Plan's allowed cost for the ultrasound is less than your required copayment, so you have been asked to pay the allowed amount rather than the full $175 copayment. The ultrasound falls within the Medicare-covered radiological diagnostic services other than x-rays 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 the ultrasound (76775) provided on July 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemtesa.
You asked the Plan to pre-approve Gemtesa. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Gemtesa.
Benefits for Gemtesa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Transcatheter placement of an intravascular stent (37239)
and the Venography (75825) provided on March 10, 2021.
You asked the Plan to pay for codes 37239 and 75825. You say that the medical records support the billing of
codes 37239 and 75825. The Plan denied your request. The Plan says the medical records do not support the
billing of codes 37239 and 75825.
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 37239 is Transcatheter placement of an intravascular
stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty
within the same vessel, when performed; each additional vein (List separately in addition to code for primary
procedure). The definition of code 75825 is Venography, caval, inferior, with serialography, radiological
supervision and interpretation.
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 codes 37239 and 75825. Our reviewer says that the medical
records do not support the billing of codes 37239 and 75825. Our reviewer found the documentation submitted
was reviewed and does not meet criteria. For code 37239, the procedure report does not include documentation
of a Transcatheter placement of an intravascular stent, and therefore cannot be confirmed as performed. Unable
to cite report, as this procedure is not documented. For code 75825, this procedure is inclusive to code 37238,
and would not be reported separately.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of codes 37239 and 75825 have not been met. Therefore, we decided that the Plan
does not have to pay for the Transcatheter placement of an intravascular stent (37239) and the Venography
(75825) provided on March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete
series of radiographic images (D0210) provided by a participating provider on August 11, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and a complete series of radiographic images.
You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says the
benefit limits for these dental services have already 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. The Plan covers a
comprehensive oral evaluation once every three years, and a complete series of radiographic images once every
five years.
We looked at the file and Medicare rules. Evidence was provided to show that these services were provided on
May 27, 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral
evaluation, and a complete series of radiographic images have not been met. Therefore, we decided that the
Plan does not have to pay for a comprehensive oral evaluation (D0150), and a complete series of radiographic
images (D0210) provided by a participating provider on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided
on July 23, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that the dentist
referred you to this doctor for necessary dental treatment. You say that you had a covered dental exam and are
appealing the denial. The Plan denied your request. The Plan says the service is not a covered benefit.
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
comprehensive periodontal evaluation (D0180) provided on July 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional speech therapy visits.
You asked the Plan to pre-approve the 12 additional speech therapy visits. You say that you would like
reconsideration because you believed these services would be covered. The Plan denied your request. The Plan
says you do not meet Medicare coverage criteria for additional visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 12 additional speech therapy visits.
Our reviewer says that the additional requested therapy is not generally accepted as specific and effective
therapy for your condition beyond what was approved by the health plan. The records do not demonstrate that
the unique skills of a professional therapist are required to safely and effectively provide treatment, that the
services can be safely and effectively performed only by a therapist, or by or under the supervision of a
therapist beyond what was approved by the health plan. Our physician reviewer found you and your caregiver
can be instructed in a home exercise program with the approved therapy. The requested services are not part of
a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow
further deterioration.
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 12 additional speech therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve 12 additional speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740).
You asked the Plan to pre-approve a crown. You say that the previous crown work you had done in January
was done incorrectly. You also say that you would like this crown to be covered under your comprehensive
coverage. The Plan denied your request. The Plan says you have met your benefit limit for this 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. The Plan covers a crown when
the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The records show that you received a crown on January 28, 2021,
therefore, your benefit limit for this service is exhausted. Based on this information, we decided that the Plan's
rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crown (D2740).
Your complaint about the previous provider's dental visit 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an abutment supported porcelain crown for teeth #6 and 8.  You asked the Plan to pre-approve the dental services. You say that extensive malpractice caused damage to your gums. The Plan denied your request. The Plan says the requested services 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.  Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment supported porcelain crown for teeth #6 and 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you $500 for hearing aids provided on June 24, 2021.  You asked the Plan to reimburse you $500 for hearing aids. You say that the hearing aids offered with this provider were less expensive than the Plan's hearing aids. The Plan denied your request. The Plan says hearing aids must be purchased by the Plan's hearing provider to receive the benefit.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the Plan's hearing provider.  We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered and provided by the Plan's hearing provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you $500 for hearing aids provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, 83789, G0480) rendered by
the out-of-network (OON) provider on July 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the drug testing services (80307, 83789, G0480) rendered by the out-of-network
(OON) provider on July 12, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (CPT code 96365) and intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (CPT code 96366) provided to the enrollee on June 30, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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 service. Our reviewer found the review indicates that CPT code 96365 (1 unit) remains not supported. The documentation submitted did not include documentation to support that intravenous infusion; initial, up to 1 hour was performed in the billed date of service; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. CPT code 96366 (4 units) remains not supported. The documentation submitted did not include documentation to support that Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) was performed on the billed date of service.; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. The review has determined that the services are not supported by the medical records provided.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (CPT code 96365) and intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (CPT code 96366) provided to the enrollee on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tissue exam (88305), anesthesia (00402), peri-implant capsulectomy (19371) and mastopexy (19316) provided on March 29, 2021.  You asked the Plan to pay for the tissue exam, anesthesia, per-implant capsulectomy and mastopexy. You say that you would like reconsideration because this procedure was medically necessary due to pain. The Plan denied your request. The Plan says this provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the tissue exam (88305), anesthesia (00402), peri-implant capsulectomy (19371) and mastopexy (19316) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig (A9282) provided on April 8, 2021.
You asked the Plan to pay for a wig. You say that the item at issue is a medical necessity for you. The Plan
denied your request. The Plan says rules for payment have not been met.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282)
provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on June 17, 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee needs to be monitored every 4
weeks. The Plan denied your request. The Plan says a network provider can care for the enrollee's medical
problem.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
ophthalmology services to be provided by an out-of-network (OON) provider.