Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 7.  You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan denied your request. The Plan says the crown is not medically necessary due to poor long-term prognosis.  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 dental service 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 pre-approve the dental service. Our reviewer says that a crown for tooth # 7 is not medically necessary. Our physician reviewer found he provided x-rays show that there is 75% bone loss around the root of tooth # 7, making the support of that tooth severely compromised. The reviewer found that crowns will not be allowed where the tooth does not demonstrate 50% bone support. The reviewer found that based on the notable loss of supporting bone, the tooth has a poor long term prognosis. Therefore, the reviewer found that the requested crown for tooth # 7 would not be considered reasonable or 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 dental service have not been met. Specifically, the file shows that tooth # 7 has a poor long term prognosis. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 7.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on August 22, 2021.  

You asked the Plan to pay for the transportation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the non-emergency transportation services are not medically necessary.  

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   

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 transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the record indicates the enrollee was transferred by via stretcher. The reviewer found that the record does not indicate that other modes of transportation could endanger the enrollee's health and that transportation by ambulance is medically required. Therefore, the reviewer found that 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 transportation services have not been met. Specifically, the file does not indicate that other modes of transportation could endanger the enrollee's health and that transportation by ambulance is medically required. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on August 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography of the thorax, diagnostic, without contrast material (71250) provided on July 21, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $0 copayment for mammography and ultrasounds and a $225 copayment for all other diagnostic and nuclear medicine radiological services.   You have been asked to pay $155.90 for the diagnostic radiological service provided. This is the Plan's allowed amount for this service which is less than the applicable copayment. 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 computed tomography of the thorax, diagnostic, without contrast material (71250) provided on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device provided on June 23, 2021, and July 23, 2021.  You asked the Plan to waive the coinsurance for a CPAP device. You say that your 13 months of payment towards ownership of this device were interrupted through no fault of your own. The Plan denied your request. The Plan says the coinsurance applied was correct.  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 20% coinsurance for in-network DME. Your contract with the Plan also clearly says that you will usually not acquire ownership of rented DME items no matter how many copayments you make. The allowed amount of each claim is $29.81, resulting in a coinsurance amount of $5.96 ($29.81 x 20%).  You have been asked to pay $11.92 for a CPAP device ($5.96 x 2 claims). A CPAP device falls within the Durable Medical Equipment (DME) and Related Supplies 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 coinsurance for a CPAP device provided on June 23, 2021, and July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the assessment and overseeing preparation of donor fecal specimen (44705) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the assessment and overseeing preparation of donor fecal specimen. You say that it is medically necessary for this care to be rendered by an OON provider. The Plan denied your request. The Plan says they have in-network providers available to treat your condition.  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 assessment and overseeing preparation of donor fecal specimen (44705) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on September 3, 2021. 

 You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment is made for this service.  

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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  

We looked at the file and Medicare rules. In this case, this claim has a Status Code of "B" under the Physician Fee Schedule indicating that it is a Bundled Code. Payment for this service is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (0012M) provided June 1, 2021.  You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the service at issue is non-covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for procedure code 0012M.  We looked at the file and Medicare rules. The billed code is non-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 pay for lab services (0012M) provided June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (procedure code 99214) provided to the enrollee on July 29, 2021.  
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The Plan says it is not appropriate to separately bill evaluation/management services in conjunction with End-Stage Renal Disease (ESRD) services.
 
 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 2021 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter."  

We find that CPT code 2021 is not supported in the medical record. Specifically, a modifier was not billed in this case to indicate the office visit as significant and separately identifiable from the ESRD services. A corrected claim has not been received. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (procedure code 99214) provided to the enrollee on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture or has tried and failed zoledronic acid.    Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our physician reviewer found that the enrollee is reported to have osteoporosis, though no test results have been provided to support this diagnosis. A request has been made for Prolia to treat the osteoporosis. She last took Prolia in June of 2019, making this a new start request, not a continuation request. The health plan requires a trial of zoledronic acid, or a history of osteoporotic fracture before they will approve the requested drug. There is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. There is no documentation as to why these other forms of medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Prolia is not shown to be currently medically necessary and reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on June 28, 2021.  

You asked the Plan to pay for the anesthesia 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.  T

he 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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).    

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that payment for this service is always bundled into payment for other services not specified and no separate payment is made. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on June 28, 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 although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than 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 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: Imaging
Decision: Favorable

 We decided that the Plan has to pay for a CT scan of the head or brain (70450) provided on December 6, 2020.  You asked the Plan to pay for a CT scan of the head or brain. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because procedure code 70450 is an overlapping, mutually exclusive service with code 70496 which was also performed on the same date of service.  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. Specifically, the billed codes on this claim are 70450 and 70498. There is not a National Correct Coding Initiative (NCCI) edit that exists between these two codes. The Plan states that the provider billed 70496 but has not forwarded any documentation to support this. The Plan has not supplied additional evidence as to why code 70450 is not supported. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for a CT scan of the head or brain (70450) provided on December 6, 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic exercises (97110) and therapeutic activities (97530) provided from August 10, 2021, to August 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the therapeutic exercises and therapeutic activities. You say that another doctor referred you to another provider for therapy and you were not aware this provider was OON. The Plan denied your request. The Plan says these services were rendered by an OON provider, and the claim does not show a referring provider. The Plan also says that OON services are not a benefit of your 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 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 the therapeutic exercises (97110) and therapeutic activities (97530) provided from August 10, 2021, to August 17, 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 dental services provided from January 8, 2021, to September 3, 2021. 

 You asked the Plan to pay for the dental services. You say that you were told that $2,000 would be paid toward getting dentures. The Plan denied your request. The Plan says payment in the amount of $2,000 has been issued by the Plan. The Plan also says that you are responsible for the remaining $2,614.00.  

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 Plan offers up to $2,000 every year for non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the dental services provided from January 8, 2021, to September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 25, 2021.  You asked the Plan to pay for the drug testing. 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 supported by the documentation.  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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.  We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copay for the Under Fracture and/or Dislocation Procedures on the Humerus (Upper Arm) and Elbow provided on May 7, 2019.  

You asked the Plan to waive the copay for these services. You say that you would like this claim reconsidered. The Plan denied your request. The Plan says that you are responsible for the copay.  

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 $225 copay for outpatient hospital surgery.   

You have been asked to pay a $225 copay for these services. These services fall within the outpatient hospital surgery 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 copay for the Under Fracture and/or Dislocation Procedures on the Humerus (Upper Arm) and Elbow provided on May 7, 2019.