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

We decided that the Plan has to pay for the intraoral - periapical first radiographic image (D0220) received May 18, 2020.

You asked the Plan to pay for the intraoral - periapical first radiographic image. You say that this provider is contracted with the Plan. The Plan denied your request. The Plan says that the provider has opted out of Original Medicare.

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 asserts that coverage of the intraoral x-ray cannot be provided because the provider in this case was opted out of Original Medicare on this date of service. We searched Medicare's database of opt-out providers; however, we found no evidence that this provider was opted out of Original Medicare. We contacted the Plan and requested the evidence or documentation used in determining this provider's opt-out status. The Plan failed to provide the requested information. Based on the available information, the Plan has failed to provide coverage in accordance with the Plan contract. Therefore, we decided that the Plan has to pay for the intraoral - periapical first radiographic image (D0220) received May 18, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse anything further for this equipment.
You asked the Plan to reimburse you for this equipment. You say that you pre-paid this equipment and the Plan should pay more of this bill. The Plan denied your request. The Plan says you will be paid the Medicare allowed amount for this equipment minus your traditional 30% coinsurance. Any amount over that rate should be reimbursed to you by the provider based on what their claim for payment was and the Medicare allowable paid rate for this type of equipment.
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 30% coinsurance for out of network durable medical equipment. The Plan cannot pay an enrollee or provider more than the Medicare allowable rate for durable medical equipment. We have confirmed that the cost of a semi-electric hospital bed in your stated is $99.06. The coinsurance per the Evidence of Coverage is 30% for out of network DME items (copayment is $29.72). Therefore, the Plan will reimburse you Medicare allowed rate which is $69.34 ($99.06 - $29.72).
Any amount in dispute over the $69.34 is between you and the out of network provider for further reimbursement as they would not have been paid by the Plan or by Medicare in the amount that you were charged. Therefore, we decided that the Plan does not have to reimburse full payment ($1653.97) for a semi-electric adjustable bed for dates of service January 7, 2021, to January 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis (L3660) provided on January 22, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the orthosis. You say that you had an emergency and was forced to go to the ER. While there they advised that the break would need a prosthetic/brace. The provider was out of network, but you did not have a choice in an emergency situation. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis (L3660) provided on January 22, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on October 15, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with records to support the drug classes being billed. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the documentation submitted does not support the number of drug classes billed on this code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolites if performed. 

We find that CPT code G0483 is supported in the medical record. Specifically, the test results show that 23 drug classes were tested. Therefore, code G0483 would be the appropriate code for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing provided on October 15, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on March 12, 2020.
You asked the Plan to waive the coinsurance for the office visit. You say that the Plan did not reach out to verify why he didn't send in proper documents. You say that this is not fair and not your fault. The Plan denied your request. The Plan says the coinsurance applied correctly.
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 50% of the Medicare-allowed amount for each out-of-network primary care provider visit for Medicare-covered services.
You have been asked to pay $35.45, which is 50% of the allowed amount for the office visit. The allowed amount is $70.90 (50% x $70.90 = $35.45). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the provider is out-of-network. 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 office visit provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the stair lift (E0621) purchased December 18, 2020.

You asked the Plan to pay for the stair lift. You say that when going up stairs you must stop and sit down to allow your BP to recover. Please consider your condition and approve the stair lift. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for the stair lift (E0621) purchased December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for pathology services provided by a
participating provider on December 10, 2020.
You asked the Plan to waive the coinsurance for pathology services. You say that you have never had to pay
for this before. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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 15%
coinsurance for outpatient diagnostic tests/in-network/diagnostic tests.
You have been asked to pay a 15% coinsurance of the allowed amount for pathology services. The allowed
amount is $738.44. The total amount you are being asked to pay is $110.76 ($738.44 x 15% = $110.76).
Pathology services fall within the outpatient diagnostic tests/in-network/diagnostic tests 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 pathology services provided by a participating provider on
December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on January 21, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed the need for the items.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 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 the continuous glucose monitor provided on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on October 23, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee requested the brace. The Plan denied your request. The Plan says the enrollee's medical condition did not support medical necessity.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis provided on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 27, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 12, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg.

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for laparoscopic surgery for
the enrollee.
You asked the Plan to pre-approve the referral. You say that it is not your fault that the plan's medical center
does not have any rooms available for surgery. The Plan denied your request. The Plan says the requested
provider is not a primary network provider.
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
a referral out-of-network for laparoscopic surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS implant (CPT code(s): C2624 and 33289), for the enrollee.
You asked the Plan to pre-approve the CardioMEMS implant. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 CardioMEMS implant. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the enrollee's current clinical symptoms and the reported NYHA Class I-II status, the enrollee does not meet current published or FDA approved indications for CardioMEMS pulmonary pressure device implantation at present and would therefore not meet the medical necessity requirements of the applicable CMS Section 1862(a)1 (A) rule. 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 CardioMEMS implant have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS implant (CPT code(s): C2624 and 33289), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultraviolet B treatments provided on October 1, 2020, through December 17, 2020.
You asked the Plan to waive the copayment for ultraviolet B treatments. You say that you did not have to pay a cost share for these services in 2019 and that you were told you would not have to pay a cost share for services in 2020. The Plan denied your request. The Plan says the copayment you are being charged is 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 $40 copayment for services obtained from a specialist.
You have been asked to pay a $40 copayment for ultraviolet B treatments ($40 x 22 visits = $880). Ultraviolet B treatments fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The record shows that there was a $40 copayment applied to each ultraviolet B treatment you received in 2019. 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 photochemotherapy ultraviolet B treatments (96910) provided on October 1, 2020, through December 17, 2020.
Your complaint about the Plan's processing of your copayment obligation 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 5, 2020 to July 10, 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 claims were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with codes matching those submitted on the RAP. 

We looked at the file and Medicare rules. The file shows that the dates billed on the claims do not match those billed on the RAP. 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 home health services rendered from June 5, 2020 to July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on October 28, 2020.
You asked the Plan to pay for the pneumatic compression device (E0676). You say that the physician prescribed this device for the medical safety of the patient. The Plan denied your request. The Plan says the device was used as a preventative service, so it is excluded from the Medicare DME equipment benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the formation of direct or tubed pedicle services coded
15574, provided on November 24, 2020.

You asked the Plan to pay for the formation of direct or tubed pedicle 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
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 15574 is formation of direct or tubed pedicle, with or
without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet.

We find that CPT code 15574 is not supported in the medical record. Specifically, the operative report did not
include documentation of a formation of direct or tubed pedicle with or without transfer of the forehead,
cheeks, chin, mouth, neck, axillae, genitalia, hands or feet; therefore, this code cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the formation of direct or tubed pedicle services
have not been met. Therefore, we decided that the Plan does not have to pay for the formation of direct or tubed
pedicle services coded 15574, provided on November 24, 2020.