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

We decided that the Plan does not have to waive the copayment for a drainage of breast lesion (19000) performed on February 26, 2021.

You asked the Plan to waive the copayment for a drainage of breast lesion. You say that you were never informed by your doctor's office that the service at issue would be billed with an outpatient hospital copayment. The Plan denied your request. The Plan says the correct copayment was 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 $300 copayment for each Medicare-covered outpatient surgery service at an outpatient hospital. 

You have been asked to pay a $300 copayment for a drainage of breast lesion. A drainage of breast lesion falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The case record indicates that the facility where the service was provided is an outpatient hospital. 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 a drainage of breast lesion (19000) performed on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Teeter inversion table with sales tax provided on February 28, 2021.

You asked the Plan to pay for a Teeter inversion table with sales tax. You say that the item at issue would be a reasonable conservative modality for treatment of your back pain. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue does not primarily serve a medical purpose.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that Medicare does not reimburse separately for sales tax.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not reimburse separately for sales tax. Therefore, we decided that the Plan does not have to pay for a Teeter inversion table with sales tax provided on February 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 84999 provided on July 7, 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 billed are not payable.

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 84999 is not supported in the medical record. Specifically, this code is an unlisted code. Explanation of unlisted codes must be on the claim or attached to the claim. This required documentation was not provided to support the services billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 84999 provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 18, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you changed providers and you were unaware of the frequency limitations. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every 36 months.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on July 19, 2019. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99211) provided January 5, 2021 to February 8, 2021.

You asked the Plan to pay for the office visit. You say that you need maintenance for your back so you can continue to function. You have received two notices of denial with a letter explanation. He has gone more times than the notices account for. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99211) provided January 5, 2021 to February 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration coded 96413 provided on February 8, 2021.

You asked the Plan to pay for the chemotherapy administration. You say that you would like the plan to reconsider their denial. 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. 

In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug.

We find that CPT code 96413 is not supported in the medical record. Specifically, the documentation shows that the enrollee underwent an infusion of Reclast for osteoporosis. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration coded 96413 provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG provided by a participating provider on February 1, 2021.

You asked the Plan to waive the copayment for an EKG. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment 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 copayment for outpatient diagnostic tests/specialist.

You have been asked to pay a $15 copayment for an EKG. The correct copayment has been applied to the diagnostic test that was provided. An EKG falls within the outpatient diagnostic tests/specialist 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 an EKG provided by a participating provider on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on December 23, 2020.

You asked the Plan to pay for the bitewing x-rays. You say that the dentist needs to take x-rays every 6 months to determine the treatment. You also say that you were not advised this service would not be covered. The Plan denied your request. The Plan says the occurrence of this procedure exceeds the number of times allowed under your contract.

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, dental x-rays are limited to 1 bitewing x-ray per year. The record shows that you received a bitewing x-ray on June 22, 2020, and your dental x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of a benign lesion (D7410) provided on
December 23, 2020.

You asked the Plan to pay for an excision of a benign lesion. You say that the service should be covered. The
Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
excision of a benign lesion (D7410) provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on April 7, 2021.

You asked the Plan to waive the copayment for vision services. You say that this should be covered fully. The Plan denied your request. The Plan says the correct copayment 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 $45 copayment for physician/practitioner services/specialist.

You have been asked to pay a $45 copayment for vision services. The correct copayment has been applied to the ophthalmology services that were provided. Vision services fall within the physician/practitioner services/specialist 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 vision services provided by a participating provider on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infectious agent detection (87798, 87482) provided on September 28, 2020.

You asked the Plan to pre-approve infectious agent detection. You say that these are Medicare covered services. The Plan denied your request. The Plan says these tests were not indicated.

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 test at issue in this appeal, infectious agent detection, was performed for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve infectious agent detection (87798, 87482) provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (64999) provided on October 25, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 64999 is "Unlisted procedure, nervous system." 

We find that CPT code 64999 is not supported in the medical record. Specifically, it is inappropriate for an anesthesia practitioner to bill anesthesia services with CPT code 64999. This code is not payable in this case. Based on this information, we decided that Medicare rules for coverage of the services have not been met.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement services provided on March 17, 2021, by an out of network provider.

You asked the Plan to pay for wound debridement services. You say that the services at issue were medically necessary and provided on an emergency basis in the absence of a contracted wound care physician. 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. The medical records provided document that the enrollee's conditions are chronic, not acute or emergent. 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 wound debridement services provided on March 17, 2021, by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies with pump (A4222) tracheal suction tube (A4624) non-disposable pump canister (A7001) tubing, used with suction pump (A7002) DME delivery, set up, and/or dispensing service component of another HCPS code (A9901) portable gaseous oxygen system (E0431) non-segmental pneumatic appliance (E0660) infusion pump system, implantable (E0776) mechanical, ambulatory infusion pump (E0780) oxygen concentrator (E1390) miscellaneous durable medical equipment (E1399) Meloxicam injection (J3490) unlisted special service, procedure or report (99199) provided October 9, 2020.

You asked the Plan to pay for the surgical supplies. You say that at the request of the enrollee's surgeon, you were asked to participate in and provide anesthesia for the enrollee's procedure. The Plan denied your request. The Plan says the billed service is not supported by the medical records.

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, we find that CPT codes A4222, A4624, A7001, A7002, A9901, E0431, E0776, E0660, E0780, E1390, E1399, J3490 and 99199 is not supported in the medical record. Specifically, the records do not contain a valid proof of delivery, or an itemized shipping/billing invoice to indicate the specific supplies and relevant medical records which support the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. For Code 99199, anesthesia services must be billed with 00100-01999 when billed by an anesthesia practitioner. Based on this information, we decided that Medicare rules for coverage of the surgical supplies have not been met. Therefore, we decided that the Plan does not have to pay for infusion supplies with pump (A4222) tracheal suction tube (A4624) non-disposable pump canister (A7001) tubing, used with suction pump (A7002) DME delivery, set up, and/or dispensing service component of another HCPS code (A9901) portable gaseous oxygen system (E0431) non-segmental pneumatic appliance (E0660) infusion pump system, implantable (E0776) mechanical, ambulatory infusion pump (E0780) oxygen concentrator (E1390) miscellaneous durable medical equipment (E1399) Meloxicam injection (J3490) unlisted special service, procedure or report (99199) provided October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee walker, bath wall rail, toilet rail, ice pack, portable bath step, scooter pad cover, shower chair, and sales tax rendered on October 23, 2020 to December 1, 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 provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 

We looked at the file and Medicare rules. The file shows that the items were purchased from a provider not certified in Medicare. 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 knee walker, bath wall rail, toilet rail, ice pack, portable bath step, scooter pad cover, shower chair, and sales tax rendered on October 23, 2020 to December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an AirSense S10 Auto, continuous positive airway pressure (CPAP) machine, and supplies.

You asked the Plan to pre-approve an AirSense S10 and supplies. You say that the item should be covered. The Plan denied your request. The Plan says that an AirSense is not a covered brand and the clinical information provided does not indicate why a preferred brand cannot meet your needs.

The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers, as long as certain conditions are met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an AirSense S10 and supplies have been met. Specifically, the AirSense S10 is a ResMed brand CPAP machine, which is a Plan preferred brand. This means the item is covered. Therefore, we decided that the Plan has to pre-approve an AirSense S10 Auto, continuous positive airway pressure (CPAP) machine, and supplies.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 12, 2020.

You asked the Plan to pay for the ambulance services. You say that your mother was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on November 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a bowel leak and for respiratory failure and pneumonia. The enrollee's medical conditions are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on March 11, 2021.

You asked the Plan to waive the copayment for lab work. You say that you should not be charged for this. The Plan denied your request. The Plan says the correct copayment 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 $12 copayment for outpatient diagnostic tests/laboratory tests. 

You have been asked to pay a $12 copayment for lab work. The correct copayment has been applied to the lab work that was provided. Lab work falls within the outpatient diagnostic tests/laboratory 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 copayment for lab work provided by a participating provider on March 11, 2021.