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

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on June 22, 2021.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that there is no history of these services having previously been provided. The Plan denied your request. The Plan says these services exceed the frequency limitations in your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on November 7, 2018 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450).

You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed based on the medical record. The Plan denied your request. The Plan says an appropriate modifier was not billed with this claim.

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. 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 computed tomography (CT) scan of the head or brain (70450).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for stereotactic body radiation therapy (SBRT) services provided on March 26, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not 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. 

The file shows that CPT code 77435 was billed on the same date of service as CPT code 77301. We find that CPT code 77435 may be eligible for payment when billed with this code combination. However, the claim provided does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for stereotactic body radiation therapy (SBRT) services provided on March 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot brace (L1960).

You asked the Plan to pre-approve the foot brace. You say that the items are medically necessary. The Plan denied your request. The Plan says there is no indication why the member cannot wear a prefabricated brace.

The Plan follows Medicare rules. Medicare rules say that if a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the foot brace. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no documentation indicating why you cannot wear a non-custom brace. You have a follow up appointment to discuss surgical options and other conservative treatment including supportive shoes, but there is no indication at this time that this has been completed. Also, the length of use for the custom brace is not indicated in the records. 

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 foot brace have not been met. Specifically, there is no indication of why a custom brace is needed over a prefabricated brace. Therefore, we decided that the Plan does not have to pre-approve the foot brace (L1960).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on October 26, 2020.

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 office visit (99214) rendered by the out-of-network (OON) provider on
October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the above knee alignable endoskeletel system addition (L5920).

You asked the Plan to pre-approve the above knee alignable endoskeletel system addition. You say that the item is medically necessary. The Plan denied your request. The Plan says the preparatory prosthesis the enrollee has is a non-alignable system because the changes that take place during the preparatory rehabilitation require follow-up. The preparatory prosthesis will need changes based on the enrollee's pattern of walking.

Therefore, this addition code is not appropriate for use on a preparatory prosthesis and is denied as not reasonable and necessary.

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 above knee alignable endoskeletel system addition. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a non-alignable prosthesis, making an alignable addition 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 the above knee alignable endoskeletel system addition have not been met. Therefore, we decided that the Plan does not have to pre-approve the above knee alignable endoskeletel system addition (L5920).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 11, 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 office visit (99214) rendered by the out-of-network (OON) provider on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient physician consultation provided on January 23, 2020.

You asked the Plan to pay for physician visit. You say that you were involved in an auto accident and this claim should be reprocessed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan is the secondary payer and cannot process this claim until after your auto insurance carrier processes the claim.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed the provider to submit this claim to your auto insurance carrier for payment. As the secondary insurer, the Plan cannot be held responsible for physician visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for an inpatient physician consultation provided on January 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on December 11, 2019.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay noncontracted
providers at the preferred provider rate if the services are not available from preferred providers.
You say that the in-network benefits should be honored, and the claim should be processed for payment. 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 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 a physical therapy assistant on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin cancer screening services rendered by a provider who has opted out of Medicare.

You asked the Plan to pay for the skin cancer screening services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says services rendered by a provider who has opted out of Medicare are not covered.

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 skin cancer screening services rendered by a provider who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 6, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that this x-ray was necessary due to you having an accident. You also say that without this x-ray the provider would not have been able to see what was wrong. The Plan denied your request. The Plan says this procedure is covered once every 36 months.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, full mouth x-rays are limited to once every 36 months. The record shows that you received a panoramic x-ray (D0330) on August 13, 2020 and your full mouth x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 23, 2021.
You asked the Plan to pay for the physical therapy. You say that services were provided at an in-network nursing facility. You say that the facility provided authorization and the doctor should be paid. The Plan denied your request. The Plan says prior authorization for out-of-network services was not 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. Therefore, we decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99211) provided on March 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 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. We find that payment for CPT code 99211 is not supported in the medical record. Specifically, CPT code 99211 is assigned an OPPS payment status indicator of "B". This means that this code is not recognized by OPPS and payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99211) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment (D9951) provided on July 2, 2021.
You asked the Plan to pay for the occlusal adjustment. You say that the service provided was not an occlusal adjustment. You also say that you believe the service should be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal adjustment (D9951) provided on July 2, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory work provided on April 1, 2021.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.
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 Plan did not show if the referring provider is an in-network or out-of-network provider. This means we cannot determine if the denial is appropriate. Therefore, we decided that the Plan has to pay for the laboratory work provided by Aegis Sciences Corporation on April 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary tract infection panel testing services provided on June 8, 2021.
You asked the Plan to pay for the services provided. You say that the lab performed the tests that were ordered. The Plan denied your request. The Plan says screening testing is not a Medicare benefit.
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. In this case, the CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. We looked at the file and the rules. The records provided do not show that the results of testing will impact clinical management of the enrollee. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the urinary tract infection panel testing services provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on June 17, 2021.
You asked the Plan to pay for the consultation. You say that you were told that the treating provider was in-network. You also say that you would like to be reimbursed for this service so you can see another provider to have the work completed. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits for consultations and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy 100MG tablet (CPT code J8499), for the enrollee.
You asked the Plan to pre-approve the medication. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says Ubrelvy is a self-administered drug, and the medication does not fall under Part B coverage. The Plan states the enrollee does not have pharmacy (drug) benefits administered by this Health Plan.
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 Ubrelvy 100MG tablet (CPT code J8499), for the enrollee.
Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift mechanism (E0627) and sales tax (S9999).
You asked the Plan to pay for a seat lift mechanism and sales tax. You say that the item should be covered. The Plan denied your request. The Plan says you received the item from a supplier who is not certified with Medicare and sales tax is not a covered benefit.
Medicare rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services.
The requested provider in this case is not certified with the Plan or Medicare. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism (E0627) and sales tax (S9999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Meningococcal vaccines and vaccine administration (90620, 90734, 90471, 90472) provided on June 3, 2021.
You asked the Plan to pay for the Meningococcal vaccines and vaccine administration. You say that you would like these claims reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says these services are not covered by Medicare.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Meningococcal vaccines and vaccine administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Meningococcal vaccines and vaccine administration. Therefore, we decided that the Plan does not have to pay for the Meningococcal vaccines and vaccine administration (90620, 90734, 90471, 90472) provided on June 3, 2021.