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

We decided that the Plan does not have to pay for the testing services rendered on October 8, 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 procedure codes U0004 and C9803 were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that testing-related services are not payable under OPPS. 

We looked at the file and Medicare rules. The services at issue are testing-related services billed under the OPPS. 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 services rendered on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on October 1, 2020.

You asked the Plan to pay for drug testing. You say that this should be covered.The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The record shows that the service at issue was billed with POS 81 for an independent laboratory, but the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator and portable oxygen system provided from September 23, 2020, through December 23, 2020.

You asked the Plan to waive the coinsurance for the oxygen concentrator and portable oxygen system. You submitted the billing statement for review. You say that the medical equipment was prescribed due to COVID.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered item.

You have been asked to pay a total of $93.56 for the oxygen concentrator and portable oxygen system provided from September 23, 2020, through December 23, 2020.

The oxygen concentrator and portable oxygen system falls within the "Durable medical equipment (DME) and related supplies" 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 coinsurance for the oxygen concentrator and portable oxygen system provided from September 23, 2020, through December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network
provider from October 21, 2020, to October 23, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.

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. 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 services provided to the enrollee by an out-of-network
provider from October 21, 2020, to October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 30, 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 testing is not covered.

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, a cardiovascular risk assessment panel, 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 rendered on May 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthoses (L1833 and L2397) provided on September 21, 2020.

You asked the Plan to pay for the knee orthoses. You say that you would like reconsideration because the orthoses were medically necessary.The Plan denied your request. The Plan says the member did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthoses have not been met. Specifically, the Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item.Therefore, we decided that the Plan does not have to pay fora knee orthoses (L1833 and L2397) provided on September 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on December 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.

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. 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 services provided to the enrollee by an out-of-network provider on December 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on October 1, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item provided is not payable.

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 relevant medical records which support medical necessity for the supplies provided in this case. Review of the file does not support a relationship between the enrollee and the ordering physician. The documentation also does not support that the enrollee had a video or telephonic visit by the ordering physician. 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 the lumbar-sacral orthosis provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on June 25, 2020.

You asked the Plan to pay for the CxBladder testing. The Plan denied your request. The Plan says this is not a covered test.

The Plan must follow Medicare rules. Medicare rules say that only the molecular bladder tests listed in the applicable LCD are covered. 

We looked at the file and Medicare rules. Per LCD L35396, CxBladder testing is not a covered molecular test. Based on this information, we decided that Medicare rules for coverage of the CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for foot inserts (A5513, A5500) provided December 16, 2020.

You asked the Plan to pay for the foot inserts. You say that the inserts were covered in the past and are medically necessary.The Plan denied your request. The Plan says the claim was filed incorrectly by the provider.

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 A5513, & A5500 are not supported in the medical record. Specifically, the provider billed with place of service 11, office. The diabetic shoe inserts are primarily for use in the enrollee's home. A corrected claim is needed from the provider. Based on this information, we decided that Medicare rules for coverage of the foot inserts have not been met.Therefore, we decided that the Plan does not have to pay for foot inserts (A5513, A5500) provided December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 5, 2020.

You asked the Plan to waive the copayment for the office visit. You say that your wife went to this doctor throughout the year and wasn't charged anything. You say that a specialist copayment should not have to be paid. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment per specialist visit. 

The enrollee has been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was with a specialist. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on November 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 28, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that the treating physician provided medically necessary services to the enrollee in good faith.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on August 22, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for this service was not filed until December 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set-up portable x-ray equipment and transportation of portable x-ray equipment services provided on November 23, 2020.

You asked the Plan to pay for the set-up portable x-ray equipment and transportation of portable x-ray equipment 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 Q0092 and R0070 are not supported in the medical record. Specifically, these services were billed with place of service 31 (Skilled Nursing Facility). However, the documentation does not support that the services were provided during a covered stay; therefore, place of service 32 would be more appropriate to be billed with these services. Based on this information, we decided that Medicare rules for coverage of the set-up portable x-ray equipment and transportation of portable x-ray equipment services have not been met. Therefore, we decided that the Plan does not have to pay for the set-up portable x-ray equipment and transportation of portable x-ray equipment services provided on November 23, 2020.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to pre-approve 3 days of Aloxi. We decided that the Plan does not have to pre-approve additional doses. 

You asked the Plan to pre-approve Aloxi. You say that Aloxi is medically necessary.The Plan says that coverage criteria has not been met.

We decided that the Plan has to pre-approve3 days of Aloxi. High emetogenic busulfan is being administered on days -4 and day -1. High emetogenic Cytoxan is being administered on day 7. Aloxi is appropriate for use for these 3 days of chemotherapy.

We also decided that the Plan does not have to pre-approve additional treatments.High emetogenicagents are not being used for other days.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on December 12, 2019.

You asked the Plan to reimburse you for the dental service. You say that you have not been able to see your regular dentist for routine care. You say that dental cleanings are covered under your coverage. You say that Periodontal cleanings are questionably covered. You also say that you were advised by a plan representative that periodontal cleanings were covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services that you receive out of network are not covered. The Plan also says that periodontal maintenance 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, dental services performed out of network are not covered. Additionally, periodontal maintenance is not among those covered under this benefit. The record shows that the plan representative advised that the periodontal cleaning could be covered based on the code submitted. The code submitted, D4910, is not covered. Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on October 9, 2020.

You asked the Plan to pay for the orthoses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not payable.

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 relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that there were no services found for the enrollee billed on the service date for the prescribing provider. In addition, there is no documentation that the enrollee received video or a telephonic visit by the ordering physician in order to warrant the codes billed. 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 the orthoses provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing tests provided on January 6, 2021.

You asked the Plan to waive the copayment for the hearing tests. You say that you were not informed of the additional copayment until three weeks later. You say that you cannot afford $90 for one visit. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for one annual routine hearing exam. Covered services include diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider. 

You have been asked to pay a $45 copayment for the hearing tests. The hearing tests fall within the "Hearing 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 hearing tests provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the massage therapy (97124), office visit (99202), x-ray exam of the spine (72020), x-ray exam of the cervical spine (72040), and the electrical stimulation (G0283) provided from October 19, 2020, through October 27, 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 these services are not a covered benefit under your contractual policy or by Medicare.

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 massage therapy (97124), office visit (99202), x-ray exam of the spine (72020), x-ray exam of the cervical spine (72040), and the electrical stimulation (G0283) provided from October 19, 2020, through October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on August 20, 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 billed diagnosis codes are mismatched.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.

We looked at the file and Medicare rules. The file shows that the services at issue were not billed with proper primary procedure 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 physician services rendered on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided from October 26, 2020 to November 30, 2020.

You asked the Plan to pay for the chiropractic services. You say that you did not know you needed authorization.The Plan denied your request. The Plan says these are not covered services.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 rules say that Medicare does not cover chiropractic maintenance care.

The records show that some of the services at issue are not manual manipulation of the spine and the others are maintenance care.Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from October 26, 2020 to November 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care provided on July 1, 2019.

You asked the Plan to pay for the initial nursing facility care. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished the claim is denied. The Plan also says that this claim was received on September 24, 2020, which is past the allowed 12 month time frame.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the initial nursing facility care was not filed until September 24, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care provided on July 1, 2019.