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

We decided that the Plan does not have to pay for the laboratory services provided on August 27, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary.

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service.

In this case, there were no medical records provided confirming that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 27, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the practitioner services/other services described by current procedural terminology (CPT) codes 95937, 95938, 95940, and A4215 provided on September 15, 2020.

You asked the Plan to pay for CPT codes 95937, 95938, 95940, and A4215. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.

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 95937, 95938, 95940, and A4215 are supported in the medical record. Based on this information, we decided that Medicare rules for coverage of CPT codes 95937, 95938, 95940, and A4215 have been met. Therefore, we decided that the Plan has to pay for the practitioner services/other services described by current procedural terminology (CPT) codes 95937, 95938, 95940, and A4215 provided on September 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection procedure for a sacroiliac joint (G0260) provided on January 21, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting by an in-network provider. 

You have been asked to pay a $350 copayment for the surgery performed in an outpatient hospital setting by an in-network provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the injection procedure for a sacroiliac joint (G0260) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation provided on December 9, 2020.

You asked the Plan to waive the copayment for the telephone evaluation. You say that you want to know why you are being charged for a 5-minute phone call. You say that if you can meet in person there shouldn't be a copayment. The Plan denied your request. The Plan says the copayment 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 a $40 copayment for services obtained from a specialist. 

You have been asked to pay a $40 copayment for the telephone evaluation. The telephone evaluation falls within the "Physician/Practitioner services, including doctor's office visits" 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 copayment for the telephone evaluation provided on December 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital after missing outpatient dialysis. He was discharged home with home health services. His medical problems are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Shingrix vaccine provided on August 4, 2020.

You asked the Plan to pay for the Shingrix vaccine. You say that if you were told the vaccine was not covered you would have never received it. The Plan denied your request. The Plan says that this vaccine is not covered under your Medicare Part B Immunization benefit.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the Shingrix vaccine by a contract provider. The file does not show that the Plan provided notice that the Shingrix vaccine would not be covered. Under Medicare rules, this means the Shingrix vaccine is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the Shingrix vaccine provided on August 4, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to the enrollee's level of weakness/fatigue and poor endurance. Care at the skilled nursing facility level appears to be appropriate in this case.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewings (D0274), and prophylaxis (D1110) provided on November 24, 2020.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewings, and prophylaxis. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered benefits 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 periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewings (D0274), and prophylaxis (D1110) provided on November 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta 5 mg tablet.

You asked the Plan to pre-approve Tradjenta. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

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 Tradjenta 5 mg tablet.

Benefits for Tradjenta 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 purchased on August 11, 2020.

You asked the Plan to pay for seat lift mechanism. You say that you can purchase items from an out-of-network
provider as long as they have not been excluded from the Plan. The Plan denied your request. The Plan
says the denial of payment for this item is correct, because this provider is not enrolled in or certified with
Medicare and is not eligible for payment.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services,
a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not eligible for
payment. Based on this information, we decided that Medicare rules for coverage of seat lift mechanism have
not been met. Therefore, we decided that the Plan does not have to pay for a seat lift mechanism purchased on
August 11, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the intermittent limb compression device provided from November 13,
2020, to November 23, 2020.

You asked the Plan to pay for the intermittent limb compression device. You say that your doctor instructed
you to wear the intermittent limb compression device. The Plan denied your request. The Plan says that
intermittent limb compression devices are not covered for preventative services.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.

You were referred for the intermittent limb compression device by a contract provider. The file does not show
that the Plan provided notice that the intermittent limb compression device would not be covered. Under
Medicare rules, this means the intermittent limb compression device is considered approved by the Plan.
Therefore, we decided that the Plan has to pay for the intermittent limb compression device provided from
November 13, 2020, to November 23, 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 pre-approve an advanced (K3) foot prostheses and a vacuum-assisted socket system.

You asked the Plan to pre-approve the requested items. You say that you need these prosthetics for your legs. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that the records must document the beneficiary's current functional capabilities.

We looked at the file, and Medicare rules. The records provided show that, with the approved prostheses, you have the ability to ambulate curbs, stairs and uneven surfaces. The records do not indicate your activity demands prosthetic utilization beyond simple locomotion. The records do not show that a level 3 prosthetic is needed for your activity level. There are insufficient records from the ordering physician indicating that a vacuum-assisted socket system is needed for the functioning and use of the approved prosthesis. Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient. Based on this information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced (K3) foot prostheses and a vacuum-assisted socket system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 1, 2020.

You asked the Plan to pay for this service. You say that this claim should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that this claim denied because the provider billed this service with an inappropriate diagnosis code. The Plan states that the provider billed a diagnosis of C79.51 for Secondary malignant neoplasm of the bone and C34.90 for Malignant neoplasm of unspecified part of unspecified bronchus or lung. The Plan states these diagnosis codes are not included in the list of indications for a PET scan for Solid Tumors Oncologic Diagnosis Codes.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate diagnosis code. In this case the claim was not submitted with an appropriate diagnosis code for the services billed, based on the records provided. Medicare billed criteria were not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on June 1, 2020 as billed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95886, 95907, 95957, 95938, 95887 and 95999) provided on September 22, 2020, through September 23, 2020.

You asked the Plan to pay for the neuromonitoring services. You say that you would like reconsideration because the claim should be processed using the group number. The Plan denied your request. The Plan says the rendering provider is a non-Medicare provider.

The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Specifically, the record indicates that the member was inpatient on the billed dates of service. Payment for these services is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95886, 95907, 95957, 95938, 95887 and 95999) provided on September 22, 2020, through September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the emergency treatment of dental pain (D9110) provided on December 11, 2020.

You asked the Plan to pay for the dental services. You say that you went to your dentist for a regular check up. You say that you had concerns about your gum and the work you had done previously. You say that the dentist advised he was going to fix the crown that was putting pressure on your gum. You also say that you were advised this would be fully covered by your insurance. The Plan denied your request. The Plan says benefits are determined based on how the claims are billed. The Plan says that limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service. The Plan also says that emergency treatment of dental pain is not listed as a covered service either.

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 limited oral evaluation (D0140), the periapical x-ray (D0220), and the emergency treatment of dental pain (D9110) provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 28, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 28, 2020.