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

We decided that the Plan does not have to pay for the dermatology services rendered on October 16, 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 has not been processed by the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has The Plan confirmed that they are not the primary insurer and have not received an Explanation of Benefits (EOB) from the primary insurer for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the dermatology services rendered on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99347) and the nail debridement (11721) rendered by the out of network (OON) provider on July 24, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the home visit (99347) and the nail debridement (11721) rendered by the out of network (OON) provider on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride application (D1206), periodontal maintenance (D4910), and intraoral x-rays (D0220, D0230) provided on December 21, 2020.

You asked the Plan to pay for the dental services. You say that your dental office was closed for most of 2020 due to the pandemic. The extra work and x-ray images were required to start new treatment. You feel the Plan should adjust/extend their COVID-19 Policy. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan's supplemental dental 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 pay for the fluoride application (D1206), periodontal maintenance (D4910), and intraoral x-rays (D0220, D0230) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care physician (PCP) office services rendered on March 18, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment. The Plan denied your request. The Plan says the copayment was 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 $15 copayment for in-network PCP's office services.

Review of the file shows that you received services from your PCP's office on March 18, 2021. You have been asked to pay a $15 copayment for these services. These services fall within the in-network PCP's office services 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 primary care physician (PCP) office services rendered on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth, completely bony, (D7240) provided on October 26, 2020.
You asked the Plan to pay for the dental service. You say that you called prior to the service. You also say that you were advised by the representative that oral surgery would be covered. The Plan denied your request. The Plan says removal of an impacted tooth, completely bony, is not listed as 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. Therefore, we decided that the Plan does not have to pay for the removal of an impacted tooth, completely bony, (D7240) provided on October 26, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 15, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you do not want to pay copayments. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for Outpatient Mental Health Care. 

You have been asked to pay a $35 copayment for the office visit. the office visit falls 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 copayment for the office visit provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on February 18, 2021.
You asked the Plan to pay for the dental items. You say that you last received dentures in 2018. You say that this was from a different provider and under a different plan. You say that you are retired and only collect Social Security. You also say that you are not able to get any adjustments done until this has been paid. The Plan denied your request. The Plan says that dentures are covered once every 5 years. The Plan says the dentures are replacements from dentures you received on December 27, 2018.
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 covers the dental items when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental items have been met. Therefore, we decided that the Plan has to pay for the complete upper denture (D5110) and the complete lower denture (D5120) provided on February 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided January 7, 2021 to January 10, 2021.

You asked the Plan to pay for the mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. 

We find that the billed services are not supported in the medical record. Specifically, the claim was not filed with a valid place of service. The plan requested a correct claim and none was provided. Based on this information, we decided that Medicare rules for coverage of the mental health services have not been met. Therefore, we decided that the Plan does not have to pay for mental health services provided January 7, 2021 to January 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on June 8, 2020.

You asked the Plan to pay for a neuromuscular stimulator. You say that this should be covered. The Plan denied your request. The Plan says there is not a valid proof of delivery for this item.

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 a valid proof of delivery for the item provided in this case. The submitted proof of delivery shows a delivery date of April 13, 2020, but this item was billed with a date of service as June 8, 2020. 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 a neuromuscular stimulator (E0745) provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), adjustable arm rests (K0108), and footplate overlay (K0108).
You asked the Plan to pre-approve an expandable controller, adjustable arm rests, and footplate overlay. You say that these items are medically necessary for the enrollee. The Plan denied your request. The Plan says it is not medically necessary to control the power options through the joystick.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria listed in the Medicare rules section. The rules also that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that arm rests are not separately payable. 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 an expandable controller. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found that the documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the upper extremities indicates that the patient can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. In addition, the adjustable arm rests are not separately payable. Finally, the footplate overlay does not serve a medical purpose. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), adjustable arm rests (K0108), and footplate overlay (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the palliative treatment (D9110), the comprehensive periodontal evaluation (D0180), the periodic oral evaluation (D0120), the prophylaxis (D1110), the panoramic x-ray (D0330), and the amalgam (D2140) provided from September 3, 2020, to November 24, 2020.
You asked the Plan to pay the full amount for the dental services. You say that you thought you automatically had $1,000 yearly coverage. You say that you did not receive a bill for any of these services until 2021. You also say that you feel these services should be covered since you thought that you would be. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that you may pay more for dental services performed out of network. The Plan also says that out of network providers are allowed to bill you for the difference between their billed amount and the plans paid amount.
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 and the oral evaluations, prophylaxis, and bitewings are covered services, you may pay more for dental services performed out of network. Additionally, the palliative treatment an amalgam are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the full amount for the palliative treatment (D9110), the comprehensive periodontal evaluation (D0180), the periodic oral evaluation (D0120), the prophylaxis (D1110), the panoramic x-ray (D0330), and the amalgam (D2140) provided from September 3, 2020, to November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGM provided on October 28, 2020.
You asked the Plan to pay for the CGM. You say that you believe the CGM was medically necessary. The Plan denied your request. The Plan says the denial of a CGM was appropriate.
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 indicates that the enrollee does not 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. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for the CGM provided on October 28, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis without contrast.
You asked the Plan to pre-approve a CT scan of the abdomen/pelvis without contrast. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.
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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. The plan did not provide any medical records in order to determine if the enrollee meets Medicare criteria for the requested CT scan. The file has no documentation showing that the Plan made any attempts to obtain medical records for review. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis without contrast.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the visual field examination provided on June 12, 2020.
You asked the Plan to pay for the services provided. You say that the medical notes substantiate the need for
the services rendered. The Plan denied your request. The Plan says that the provider is not billing in accordance
with what services were performed.
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 92083 is Visual field examination, unilateral or bilateral,
with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted
and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus
program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2)
We find that CPT code 92083 is supported in the medical record. The records provided show that Humphrey
visual field testing was performed. Based on this information, we decided that Medicare rules for coverage
have been met. Therefore, we decided that the Plan has to pay for the visual field examination provided on June
12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that you require services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 20, 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 20, 2020.