Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from September 24, 2019 to February 13, 2020.
You asked the Plan to waive the copayments for the wound care. You say that you do not believe the wound care is a surgical procedure. You say the copayments have been piling up and are a burden. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 surgery services at an in-network outpatient hospital. You have been asked to pay a total of $2,405.07 for the wound care. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that wound care is considered a surgical procedure. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
September 24, 2019
Wound care
$137.96
$175
$137.96
September 24, 2019
Wound care
$118.72
$175
$37.04
September 27, 2019
Wound care
$137.96
$175
$137.96
October 1, 2019
Wound care
$137.96
$175
$137.96
Date of Service
Service
Allowed Amount
Copayment
Member Liability
October 8, 2019
Wound care
$137.96
$175
$137.96
October 14, 2019
Wound care
$137.96
$175
$137.96
October 17, 2019
Wound care
$137.96
$175
$137.96
October 22 , 2019
Wound care
$180.82
$175
$25.00
October 29, 2019
Wound care
$137.96
$175
$137.96
December 3, 2019
Wound care
$137.96
$175
$137.96
December 10, 2019
Wound care
$180.82
$175
$25
December 17, 2019
Wound care
$137.96
$175
$137.96
December 23, 2019
Wound care
$137.96
$175
$137.96
December 31, 2019
Wound care
$137.96
$175
$137.96
January 7, 2020
Wound care
$136.44
$175
$136.44
January 14, 2020
Wound care
$136.44
$175
$136.44
January 21, 2020
Wound care
$136.44
$175
$136.44
January 28, 2020
Wound care
$136.44
$175
$136.44
February 4, 2020
Wound care
$136.44
$175
$136.44
February 13, 2020
Wound care
$118.27
$175
$118.27
Total
$2,405.07
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 copayments for the wound care provided from September 24, 2019 to February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services.

You asked the Plan to pay for the psychotherapy services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible to participate in the Medicare program.

We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a prefabricated knee orthosis (L1833) and a suspension sleeve (L2397) provided on August 21, 2020.
You asked the Plan to pay for a knee orthosis and suspension sleeve. You say that the enrollee is using the item and it is helping the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a knee orthosis and suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case. There is no documentation of a recent injury to or a surgical procedure on the knee(s). There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. The requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a prefabricated knee orthosis (L1833) and a suspension sleeve (L2397) provided on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960).

You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the enrollee is using the item and finds it helpful. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a shoulder-elbow-wrist-hand orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was right shoulder pain. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing visits provided in the home health setting.

You asked the Plan to pay for the home health nursing visits. You say that this claim was submitted for nursing services through the correct code, G0299. You are a professional provider, and the services were provided in the enrollee's home. You believe this was billed correctly. The Plan denied your request. The Plan says this was not billed on the appropriate claim form.

The Plan must follow Medicare rules. Medicare rules say that payment can only be made for home health services provided by a registered HHA. The rules also say that HHAs must submit claims on the institutional claim form.

Since G0299 represents home health services, they are only eligible for payment from an HHA when submitting on an institutional claim. This was submitted on a professional claim. As such, the rules for payment have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing visits provided in the home health setting.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 81000 is not supported.
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 81000 is urinalysis, by dip stick or tablet reagent for
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any
number of these constituents; non-automated, with microscopy.
We find that CPT code 81000 is not supported in the medical record. Specifically, there is no documentation of
urinalysis by dip stick or tablet reagent with microscopy results. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory services rendered on July 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on April 28, 2020.
You asked the Plan to pay for the physician services. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the critical care services provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81445, 0018U) provided August 21, 2020.
You asked the Plan to pay for the lab services. You say that the testing performed was medically necessary and should be covered. The Plan denied your request. The Plan says the provided documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due. We looked at the file and Medicare rules. No medical records were provided to support the testing performed. 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 (81445, 0018U) provided August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D1999).

You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Code D1999 is not listed as a covered service in the plan contract. Therefore, we decided that the Plan does not have to pay for dental services (D1999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug.

You asked the Plan to waive the coinsurance for the Part B drug. You say that you had been paying less than
$20 for cancer treatments. The Plan denied your request. The Plan says you have been charged the correct cost
sharing amount.

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 20%
coinsurance for Medicare Part B prescription drugs.

You have been asked to pay $688 which is 20% of the allowed amount for the Part B drug. The allowed
amount is $3,440.04. ($3,440.04 x 20% = $688). The record shows you received an injection of UDENYCA.
The Part B drug falls within the "Medicare Part B prescription drugs" 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 the Part B drug.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID-19
executive order for treatment in place. The Plan denied your request. The Plan says these services are not a
covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance service.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 21, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel that this service should be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation 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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on May 22, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0274, D0150, D0220) provided by an out-of-network (OON) provider.

You asked the Plan to pay for OON dental services. You say that you had to go to an OON provider because your network dentist was not taking patient. The Plan denied your request. The Plan says OON dental 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, services received out-of-network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D0274, D0150, D0220) provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided from February 12, 2020, to March 19, 2020.
You asked the Plan to waive the copayments for the psychotherapy visits. You say that your therapist was on the approved provider list before you signed up for the insurance. The Plan denied your request. The Plan says the claims were reprocessed as in-network and you have been charged the correct cost sharing amount
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 $10 copayment for in-network specialist's office. You have been asked to pay a $10 copayment for each of the psychotherapy visits. The psychotherapy visits fall within the "Outpatient mental health care" 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 copayments for the psychotherapy visits provided from February 12, 2020, to March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture (D5110) provided October 7, 2020.
You asked the Plan to pre-approve the partial denture. You say that the upper denture was medically necessary. The Plan denied your request. The Plan says this item 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 pre-approve a partial denture (D5110) provided October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cone Beam CT scan (D0364).

You asked the Plan to pre-approve the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says this 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 pre-approve a Cone Beam CT scan (D0364).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 and drug testing coded 80307.

You asked the Plan to pay for the office visit and drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 CPT codes 99214 and 80307 are not supported in the medical record. Specifically, these codes were billed with diagnosis code M54.5. This is an incomplete diagnosis code as diagnosis codes should have five digits and this one was submitted with four. Based on this information, we decided that Medicare rules for coverage of the office visit and drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 and drug testing coded 80307.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high intensity focused ultrasound.

You asked the Plan to pre-approve the ultrasound. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of moderate to severe postural or intention tremor of the dominant hand.

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 ultrasound. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the medical records indicate a history of essential tremors that was later diagnosed as Parkinson's disease. The available medical records do not indicate a trial of medical therapy, disabling tremors or whether the enrollee is a candidate for deep brain stimulation. Therefore, the local coverage criteria are not satisfied according to the provided documentation and the requested service cannot be recommended.

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 ultrasound have not been met. Therefore, we decided that the Plan does not have to pre-approve high intensity focused ultrasound.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and administration (90471) provided on October 7, 2020.
You asked the Plan to pay for a Tdap vaccine and administration. You say that this was part of your wellness visit. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine and administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and administration (90471) provided on October 7, 2020.
Benefits for a Tdap vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.