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

We decided that the Plan does not have to waive the copayment for manual manipulation of the spine (98940) and pay for the manual therapy services (97140) provided on March 22, 2021, through April 12, 2021.

You asked the Plan to waive the copayment for the manual manipulation of the spine. You say that you should not have to pay a cost share on these claims as you have been seeing this provider and he has helped you in your daily life. 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). The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. Your contract with the Plan clearly says that you must pay a $25 copayment for the manual manipulation of the spine for chiropractic services. Your contract with the Plan also clearly states that we cover only manual manipulation of the spine to correct subluxation; therefore, the manual therapy services are not covered. 

You have been asked to pay a $25 copayment for each manual manipulation of the spine visit with an out-of-network provider. The EOC confirms you pay a $25 copayment for each out-of-network visit. The Medicare Allowed Amount for each visit at issue is $23.37. This is lower than your required copayment responsibility of $25. You have a total of three (3) visits for a total cost share of $70.11 ($23.37 x 3 visits = $70.11). The manual manipulation of the spine falls within the chiropractic services benefit category. The records show that the manual therapy services are not manual manipulation of the spine. 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 manual manipulation of the spine (98940) and pay for the manual therapy services (97140) provided on March 22, 2021, through April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (G0480) rendered by the out of network (OON) provider on March 3, 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 drug testing (G0480) rendered by the out of network (OON) provider on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay up to $400 for the extractions. We decided that the Plan does not have to pay more than $400 for the extractions.
You asked the Plan to pay for to pay for the extractions. You say that you needed to have these teeth pulled. The Plan says that these services are not covered.
We decided that the Plan has to pay up to $400 for the extractions.
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 offers a $400 flex benefit that covers comprehensive dental services, including extractions. The record shows that you received multiple extractions, and the Plan denied these services saying they are not covered. The EOC states that you have a $400 flex benefit, and extractions are covered under your comprehensive dental benefit. The EOC does not clearly state that extractions are not covered, or that you are not able to use the $400 flex benefit toward the extractions. You reasonably believed up to $400 worth of the extractions would be covered under your flex benefit. Therefore, we decided that the Plan has to pay up to $400 for the extractions.
We also decided that the Plan does not have to pay more than $400 for the extractions.
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 a $400 annual flex benefit. The contract clearly states that you are responsible for any amount over the $400 plan benefit limit. Therefore, we decided that the Plan does not have to pay more than $400 for the extractions.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from January 1, 2021, to January 15, 2021.

You asked the Plan to pay for the home visits. You say that you followed protocol in seeking pre-authorization for the services, and were very transparent of the services that would be provided.The Plan denied your request. The Plan says the treating provider is not Medicare certified.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met.Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis (99512) provided from January 1, 2021, to January 15, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for one unit each of three levels of paravertebral facet joint injections (64493, 64494, 64495) provided on October 29, 2020.

You asked the Plan to pay for paravertebral facet joint injections. You say that only one unit of each code was billed. The Plan denied your request. The Plan says that the units billed exceeds MUE.

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 states that two units of each code were billed. However, the claim form included in the case file shows only one unit of each code was billed. The Plan has not submitted documentation showing that additional units were billed. Therefore, we decided that the Plan has to pay for one unit each of three levels of paravertebral facet joint injections (64493, 64494, 64495) provided on October 29, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning and inspection of removable complete denture, maxillary and mandibular (D9932, D9933) received March 1, 2021.

You asked the Plan to pay for the cleaning and inspection of removable complete denture, maxillary and mandibular (D9932, D9933). You say that you received a routine cleaning. These codes begin with the word "cleaning" so they should be covered. The Plan denied your request. The Plan says the services you received are separate and distinct from a routine cleaning.

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. The requested services are not routine dental cleanings. Therefore, we decided that the Plan does not have to pay for the cleaning and inspection of removable complete denture, maxillary and mandibular (D9932, D9933) received March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 5, 2021, through February 6, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated in the emergency department and observed as necessary in the facility.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 39-year-old female member who presented to the hospital Emergency Department (ED) on February 5, 2021 due to abdominal pain that began during her hemodialysis session. The enrollee was admitted for a workup for possible early peritonitis versus non occlusive mesenteric ischemia. The enrollee was treated with Ceftazidime / Vancomycin IC, a Gastrointestinal consult for possible mesentery thrombosis. A computerized tomography recommended but the enrollee refused and received hemodialysis treatment. Her condition stabilized and improved, and she was discharged on February 6, 2021 with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 5, 2021, through February 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0481) provided April 1, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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. We find that CPT code G0481 is not supported in the medical record. Specifically, the place of service listed on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Additionally, the date of service on the claim does not match the date of service in the records. 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 (G0481) provided April 1, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with diabetes,
lymphedema, asthma, obesity, sleep apnea and chronic kidney disease. From a nursing perspective, the enrollee
received oral medications. The enrollee had stable vital signs. He was treated for pain with effect. Regarding
rehabilitation services, the enrollee received physical therapy in the home setting. The enrollee was nonambulatory
and required a mechanical lift for transfers. He could move in bed with contact guard assist.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on June 9, 2020.

You asked the Plan to pay for the infectious agent detection by nucleic acid. You say that this COVID-19 claim has not been paid to this date. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on June 9, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 30, 2020.

You asked the Plan to pay for the laboratory services. You say that The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L3170, L1971) provided December 19, 2020.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied your request. The Plan says the items were provided following an unsolicited phone call to the enrollee and there is no record of a physical exam.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances. We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses (L3170, L1971) provided December 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367), and the panoramic radiographic image (D0330) received January 26, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation and the panoramic radiographic image. You say that you should not owe any money for these services because you were not told how much they would cost. The Plan denied your request. The Plan says there is no coverage for cone beam CT capture, and the frequency limitation for panoramic radiographic images has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
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 or are in excess of what is covered under this benefit. The Plan does not offer coverage for cone beam CT capture. The Plan limits coverage of panoramic radiographic images to once every 36 months. The Plan has submitted evidence that you last received, and the Plan covered, a panoramic radiographic image on May 15, 2020. When you received the panoramic radiographic image on January 26, 2021 the benefit was exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367), and the panoramic radiographic image (D0330) received January 26, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for needle electromyography provided on June 5, 2020.
You asked the Plan to pay for needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) (95957). You say that the procedure is supported in the medical record. The Plan denied your request. The Plan says that the procedure is not supported in the medical record.
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 95957 is needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure). 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 needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) (95957). Our reviewers say that documentation submitted was reviewed, and does meet criteria. Our physician reviewer found procedure report documents CPT 95887 "For triggered EMG used during the lateral approach the surgeon utilized an electrified dilator to deliver a current between G and 10 mA. EMG activity was monitored continuously to assess proximity to neural elements. Muscle responses were recorded using subdermal needle electrodes". We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure) (95957) have been met. Therefore, we decided that the Plan has to pay for needle electromyography provided on June 5, 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 pay for a knee wheeler (E0118) provided on January 15, 2021, by an out of network provider.

You asked the Plan to pay for a knee wheeler. You say that you were not aware that durable medical equipment must come from a contracting supplier. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a knee wheeler (E0118) provided on January 15, 2021, by an out of network provider.