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

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on November 25, 2019.You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on November 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the destruction services coded 17003 and 17110, and the tangential biopsy of skin services coded 11103 provided on December 10, 2019.
You asked the Plan to pay for the destruction services and the tangential biopsy of skin 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 supported by the documentation.
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 17003, 17110, and 11103 are not supported in the medical record. Specifically, the documentation submitted indicate that cryosurgery was planned; however, the medical records do not include a cryosurgery procedure note to support that cryosurgery was performed on the billed date of service. Therefore, code 17110 is not supported by the documentation. Since the preceding procedure code of 17110 was denied, codes 17003 and 11103 cannot be separately reimbursed. Based on this information, we decided that Medicare rules for coverage of the destruction services and the tangential biopsy of skin services have not been met. Therefore, we decided that the Plan does not have to pay for the destruction services coded 17003 and 17110, and the tangential biopsy of skin services coded 11103 provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the medical services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network providers available that can provide the care the enrollee is seeking.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 8, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 subsequent nursing facility care provided on October 8, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you require the compression
stockings to help with leg swelling. The Plan denied your request. The Plan says Medicare does not cover
garments unless they are being used to dress a wound or with a medical device. Your request does not include
either of these reasons.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you
do not have a medical condition for which compression stockings can be covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code
A6530.
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.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your functional level does not require or indicate that this therapy must be in an IRF with an intensive level 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive periodontal evaluation - new or established
patient (D0180), full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a
subsequent visit (D4355) and intraoral - complete series of radiographic images (D0210) provided from
January 15, 2020 through January 23, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you would like the claims to be reprocessed and
paid at your 50% coverage rate. The Plan denied your request. The Plan says they have made multiple attempts
to obtain records from your dental provider but no records were received for this dental visit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore,
the services are not covered. Therefore, we decided that the Plan does not have to pay for comprehensive
periodontal evaluation - new or established patient (D0180), full mouth debridement to enable a comprehensive
oral evaluation and diagnosis on a subsequent visit (D4355) and intraoral - complete series of radiographic
images (D0210) provided from January 15, 2020 through January 23, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482 and CPT 80307) provided to the enrollee on December 30, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, any number of devices orprocedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS,RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed,per date of service HCPCS G0482: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individualdrugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognizedinternal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variationsand mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drugclass(es), including metabolite(s) if performed 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found based on the records provided documentation does not support the coding of the denied codes. The records do not provide any evidence of a relationship between the enrollee and the ordering physician. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482 and CPT 80307) provided to the enrollee on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on
January 17, 2020.
You asked the Plan to pay for the dental services. You say that you and your provider called the dental provider
to confirm that the bitewing x-rays would be covered. The Plan denied your request. The Plan says you
exhausted your benefit frequency limit.
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.
You exhausted your benefit frequency limit, because you had this service on January 28, 2019. Your EOC
states, bitewing x-rays every twelve (12) months (one set - up to four films). Therefore, we decided that the
Plan does not have to pay for bitewings - four radiographic images (D0274) provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.You asked the Plan to pre-approve the compression stockings. You say that you have a history of deep vein thrombosis, hypertension, and hyperlipidemia. You would like a replacement pair of stockings.The Plan denied your request. The Plan says there is no qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient (CPT Code 92002) provided on July 25, 2019 by an out-of-network provider.
You asked the Plan to pay for the vision care services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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 has network providers available who can provide 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 ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient (CPT Code 92002) provided on July 25, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered on December 8, 2019.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that the panel must be billed with procedure code 81479. The file shows that the panel was not billed with code 81479 but as a panel of codes. 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 testing rendered on December 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve white glass with high gold content crown, tooth #28
(D2750), for the enrollee.
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied
your request. The Plan says the rules were not met for tooth #28.
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
services when the services are medically necessary and reasonable.
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 dental services. Our physician
reviewer found the documentation provided does not show that there is significant breakdown of the coronal
structure of tooth #28 due to caries or fracture to meet the criteria for coverage for a crown restoration (D2750).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does
not have to pre-approve white glass with high gold content crown, tooth #28 (D2750), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from August 20, 2019 through March 20, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the dental service reported is eligible only if it is a direct result of an accident. The Plan states the reported service would not be performed in conjunction with an accidental injury; therefore, no payment can be made for this 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. Review of the file show that you received dental services from August 20, 2019 through March 20, 2020. Your EOC states, non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician). Therefore, we decided that the Plan does not have to pay for the dental services provided from August 20, 2019 through March 20, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid purchased on June 24, 2019 from an out-ofnetwork
provider.
You asked the Plan to pay for the hearing aid. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says there is no coverage for hearing aids when provided by
an out-of-network provider.
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 has network providers
available who can provide 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 hearing aid purchased on June 24, 2019 from an
out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram (77063, 77067) provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the mammogram. You say that the services should be covered. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the mammogram (77063, 77067) provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy (97014) and the therapeutic exercises (97530) provided on July 15, 2019.
You asked the Plan to pay for the electric stimulation therapy and the therapeutic exercises. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under the member's contractual policy.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy (97014) and the therapeutic exercises (97530) provided on July 15, 2019.