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

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on April 27, 2021.
You asked the Plan to pay for the dental service. You say that this was an emergency visit for a tooth abscess that required antibiotics. You also say that the treatment was necessary. The Plan denied your request. The Plan says 1 complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.
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 complete series x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray
that you received on March 20, 2021. Therefore, we decided that the Plan does not have to pay for the complete
series x-ray (D0210) provided on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomographic (CT) scan of the chest (71275) provided on September 14, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for a CT scan of the chest. You say that you disagree with the denial as the referring provider orders the services that are needed in order to render an accurate diagnosis of the patient. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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 records provided for review also show that the enrollee was referred by a non-participating provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a computed tomographic (CT) scan of the chest (71275) provided on September 14, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 22, 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 looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 8, 2021.
You asked the Plan to pay for subsequent nursing facility care (99309SA). You say that the Plan should pay
this claim. The Plan denied your request. The Plan says Medicare does not accept modifier SA and the
submitted documentation supported services rendered by the doctor but did not indicate services rendered by a
separate nurse practitioner.
The Plan must follow Medicare rules. The rules say that modifier -SA is used when a nurse practitioner
rendered service in collaboration with a physician for supervised nurse practitioner services for any procedure
that does not include surgery. However, Medicare does not accept the SA modifier.
Medicare does not allow the SA modifier. Therefore, we decided that the Plan does not have to pay for
subsequent nursing facility care provided on April 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 4, 2021.

You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 the ambulance services. Our reviewer says that the documentation does not support that the Our physician reviewer found the enrollee was transported via ambulance for lift assist due to the enrollee not being able to ambulate on own. The enrollee had no complaints except for weakness and that the enrollee's medications make the enrollee use the bathroom too often.

The enrollee was assessed as having stable vitals and was in no distress. Based on the documented clinical presentation the symptoms do not meet prudent layperson criteria for emergency care. There was no contraindication to using a stretcher van or wheelchair van based on the documentation. The documentation did not support that the enrollee required special services or equipment. Therefore, the enrollee did not meet criteria for the rendered services. 

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
August 20, 2020, to August 25, 2020.
You asked the Plan to waive the copayment for the inpatient services. You say that you have never received
this kind of copay for any of your previous surgeries. You cannot afford this tremendous amount. The Plan
denied your request. The Plan says the claim was processed with the correct copayment applied per the
Evidence of Coverage.
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 $250 per
day for days 1-7 for Inpatient hospital care.
You have been asked to pay $1,2500 ($250 x 5 days) for the inpatient services. The inpatient services fall
within the Inpatient hospital 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 inpatient hospital services provided August 20, 2020, to August 25, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on December 4, 2020, to December 18, 2020.
You asked the Plan to waive the copayment for wound care. You say that you think this is fraud. You say that you thought your copayment would be $35. 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 $250 copayment for outpatient surgery/hospital facility. You have been asked to pay a $250 copayment for wound care. The total amount you are being asked to pay is $500 ($250 + $250 = $500). The correct copayment has been applied to the services that were provided.
Wound care falls within the outpatient surgery/hospital facility 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 wound care provided by a participating provider on December 4, 2020, to December 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric treatment.
You asked the Plan to pre-approve inpatient psychiatric treatment. 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 inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric treatment. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based upon review
of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental health
treatment for the dates in question of September 1, 2021, forward as this enrollee was not shown to be a danger
to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant
with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute
threats of safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric treatment have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient psychiatric treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).

You asked the Plan to pre-approve Vertiflex procedure. You say that this procedure is considered safe and effective, and the enrollee is a good candidate. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Food and Drug Administration states that the Superion Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1 spondylolisthesis, confirmed by imaging evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. The Superion Interspinous Spacer is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain,
with or without back pain, who have undergone at least 6 months of non-operative treatment. The Superion Interspinous Spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The records indicate that the enrollee has chronic low back pain and lumbar spinal stenosis with spinal stenosis. The record indicates that imaging has demonstrated moderate to severe spinal stenosis at L4-L5, the level requested for treatment. The record indicates than pain is worsened in flexion. Therefore, this service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from January 8, 2021, to January 12, 2021.

You asked the Plan to pay for the hospital services. You say that you were credentialed with the Plan at the time of service. The Plan denied your request. The Plan says the facility was not found listed on Data.Medicare.gov Hospital General Information or Medicare.gov Hospital Compare websites.

The Plan must follow Medicare rules. Medicare rules say that no provider shall receive payment for services furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program.

We looked at the file and Medicare rules. Centers for Medicare and Medicaid Services (CMS) does not pay providers who are not enrolled. The facility is not registered with Medicare. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services provided from January 8, 2021, to January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 23, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you are requesting the claim be processed at the contracted rate. The Plan denied your request. The Plan says services rendered by non-participating providers require 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 office visit provided on December 23, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided
on August 25, 2020.

You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that
the place of service code is correct. The Plan denied your request. The Plan says the device is not covered by
Medicare to prevent deep vein thrombosis during and/or following surgery and payment for this device would
have been included in the facility payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0675) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for the pneumatic compression device and appliances provided on August
25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral screening digital breast tomosynthesis (77063) and bilateral screen mammography (77067) provided on February 8, 2021.
You asked the Plan to pay for the digital breast tomosynthesis and mammography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 77067 and 77063 and 77066.
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 have confirmed that codes 77063 and 77067 have a bundled relationship with code 77066 and cannot be paid as billed. These codes cannot be paid as separate line items. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for bilateral screening digital breast tomosynthesis (77063) and bilateral screen mammography (77067) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81226, 81240, 81241, and 81225 provided on December 16, 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 codes 81226, 81240, 81241, and 81225 are not supported in the medical record. Specifically, if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis code. If no code accurately describes the procedure performed, the laboratory may report code 81479 (Unlisted molecular
pathology procedure) with one unit of service or may report multiple individual codes describing the component test results when medically reasonable and necessary. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Review of the file shows that more than one code was billed for the services rendered. 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 81226, 81240, 81241, and 81225 provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist physician services provided on
February 23, 2021.
You asked the Plan to waive the copayment for specialist physician services. You say that the procedure for
ambulatory continuous glucose monitoring never happened. You say that you should not be charged for
something that did not happen. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
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 $40
copayment for each specialist visit for Medicare-covered services.
You have been asked to pay $40 copayment for specialist physician services. Specialist physician services fall
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The record shows
you had an office visit with a specialist, which included glucose monitoring services. 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 physician services with a specialist provided on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2021.

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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the skilled nursing facility (SNF) care provided from October 10, 27, 2020, to October 29, 2020.

You asked the Plan to pay the in network rate for the SNF care. You say that this facility is in network. You say that you received a bill for $530.09. You say that you feel this is too much for a facility that was in network. You also say that the facility has since changed its name. The Plan denied your request. The Plan says the claim was processed correctly at the out of network rate. The Plan also says that the facility in this case was out of network on the dates of service in this case.

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 40% coinsurance for out of network care for skilled nursing facility care.

You have been asked to pay 40% coinsurance for the out of network SNF care. The SNF care falls within the skilled nursing facility 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. The record shows that the facility was not in network with the Plan until November 1, 2020. Therefore, we decided that the Plan does not have to pay the in network rate for the skilled nursing facility (SNF) care provided from October 10, 27, 2020, to October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 30, 2021.
You asked the Plan to pay for the dental services. You say that the nurse told you there would only be a copay. The Plan denied your request. The Plan says the services are 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. The file show that an intraoral x-ray, extractions, and consultation were provided on the date of service at issue. Although the Plan offers a dental benefit in excess of Medicare coverage, the services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 30, 2021.
Your complaint about potential misinformation from the dental office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.