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

We decided that the Plan does not have to pay for the chemical cauterization of granulation tissue (17250 x 4) and the debridement of subcutaneous tissue (11042) rendered by the out-of-network (OON) provider on January 27, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chemical cauterization of granulation tissue (17250 x 4) and the debridement of subcutaneous tissue (11042) rendered by the out-of-network (OON) provider on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on October 1, 2020.
You asked the Plan to reimburse you for hearing aids. You say that you were not aware you needed to use a Plan vendor. The Plan denied your request. The Plan says that the Plan requires the member to obtain covered services, except for emergency care and out-of-area urgent care, from Plan providers. The routine services provided to the member by non-Plan provider are not covered because they were not authorized by the Plan, not emergent, and not urgently needed while the member was outside the Plan's service area.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has 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 hearing aids. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), and a filling (D2331) provided on April 14, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image, and a filling. You say that you were told you could go to this provider. The Plan denied your request. The Plan says the intraoral periapical radiographic image is a covered benefit, but you have exceeded the frequency limit of one every calendar year. The filling is a covered benefit, but you have exceeded the frequency limit of two per calendar year.
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 an intraoral periapical radiographic image, and a filling have not been met. Specifically, the record shows that you had exceeded the frequency limit for the intraoral periapical radiographic image prior to this service on April 1, 2021.
Additionally, you had exceeded the frequency limit for fillings. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), and a filling (D2331) provided on April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested dispensing plan of this drug meets for Part D coverage, as the pharmacy is dispensing the drug to the enrollee to self-administer.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be given to the enrollee to self-administer. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on November 7, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions are only covered if they are routine and performed by a Plan routine vision care provider.

The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on November 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on November 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan provided on April 17, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for the copayment amount. The Plan denied your request. The Plan says you have been asked to pay 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 a $225 copayment for in-network advanced imaging service (not including x-rays). You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for CT scan provided on April 17, 2021.
Your complaint that your provider did not treat you 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmoscopy (92202) provided April 1, 2021.
You asked the Plan to pay for the ophthalmoscopy. You say that the services were medically necessary. The
Plan denied your request. The Plan says the number of units billed exceeds the allowed amount.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 2 units of CPT code 92202 are not supported in the medical record. The medical record only
supports 1 unit of CPT code 92202. The procedure is either bilateral or unilateral and is not a per-eye
procedure. 2 units were billed by the same provider on the same date of service. Based on this information, we
decided that Medicare rules for coverage of the ophthalmoscopy have not been met. Therefore, we decided that
the Plan does not have to pay for an ophthalmoscopy (92202) provided April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (G0482) provided to the enrollee on June 30, 2020.

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 Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 (G0482) provided to the enrollee on June 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998)
provided August 28, 2020.

You asked the Plan to pay for the ambulance response. You say that you thought you were doing the right thing
by not taking the ambulance which would have led to hospital fees. The Plan denied your request. The Plan
says ambulance services are not covered when there is not transport.

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 August 28, 2020. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
The trip report in this case shows that you were feeling better and refused transport to the hospital and thus the
wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response
and treatment, no transport (A0998) provided August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 9, 2021.
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 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 rendered on February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's needs are met at the current inpatient setting. The LTACH does not offer any service the current facility cannot provide.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for acupuncture services provided from January 13, 2021 to April 2, 2021.

You asked the Plan to reimburse you for the acupuncture services. You say that the Plan advised you that acupuncture treatment is covered. The Plan denied your request. The Plan says the provider is not certified with Medicare therefore the claim denied correctly.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for acupuncture services provided from January 13, 2021 to April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64495).
You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when medically necessary. 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 facet joint injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found there is no documentation indicating that the pain has been present for minimum of 3 months with documented failure to respond to non-invasive conservative management. There is no documentation that there is no non-facet pathology.
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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64495).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on March 3, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that according to the documentation these services should be covered, but at a lesser rate, for services received OON. The Plan denied your request. The Plan says routine preventive dental services are not covered when rendered by an OON provider. The Plan also says that services provided must be received at a participating provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays provided on March 3, 2021 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you are a fall risk. The Plan denied your request. The Plan says you no longer require skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
Continued SNF services beyond August 27, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, were treated for pain, and your lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist to supervision level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or skilled therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on March 31, 2021.
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician to help guide them through the process of selecting the appropriate treatment to achieve the best possible outcome. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the documentation does not show that the enrollee met the criteria for this testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing was correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on March 31, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (93224) provided to the enrollee on December 1, 2020.
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 there is no documentation of electrocardiographic recording or ordering of same
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 93224 is "External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional." We find that CPT code 93224 is not supported in the medical record. Specifically, the medical records show a ketamine infusion procedure. There is no mention of anything related to CPT 93224. 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 physician services (93224) provided to the enrollee on December 1, 2020.