Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis.

You asked the Plan to pay for the orthosis. You say that a physical exam is not required during the pandemic. The Plan denied your request. The Plan says the enrollee's claim history does not show a claim for the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that the medical record must contain sufficient documentation of the enrollee's medical condition to substantiate the necessity for the type and quantity of items ordered.

We find that the lumbar orthosis is not supported in the medical record. The file shows that the records in the case file were based on a phone conversation with the enrollee. The file does not include previous medical records showing the enrollee's clinical course, extent of functional limitations, or other therapeutic interventions and results. There are no records to show that this enrollee has ever been treated for this condition. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar orthosis.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services.

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 95913 and 95886 are not supported.

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 95913 is nerve conduction studies; 13 or more studies. The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).

We find that CPT codes 95913 and 95886 are not supported in the medical record. Specifically, there is no documentation of 13 or more nerve conduction studies to support code 95913. Given that the primary procedure code is not supported, add-on code 95886 is also not supported. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the physician office visit. You say that you were not aware prior authorization would be necessary. The Plan denied your request. The Plan says this service done by an out-of-network provider and the services are not urgent or emergent nor 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 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 the medical services provided on June 1, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and to waive the out of network cost share for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and panoramic x-ray (D0330).

You asked the Plan to pay for the dental services. You say that the check that you received for reimbursement does not cover the items that you received. You say that a plan representative assured you that the cleaning and x-rays are covered. You also say that you should be reimbursed the proper amount. The Plan denied your request. The Plan says periodontal maintenance is not listed as a covered dental service. The Plan says that there is a $40 copayment for each office visit with an out of network provider. The Plan says cost sharing amounts are out of network providers may bill you for any amount greater than the payment made by the plan to the 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, periodontal maintenance is not among those covered under this benefit. Each visit to an out of network dentist has a $40 copayment. Additionally, you may be billed more by amount of network provider if the charge is greater than MAC. Cost sharing is a contractual obligation under the plan and cannot be waived. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) and to waive the out of network cost share for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and panoramic x-ray (D0330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses provided by an out of network provider.

You asked the Plan to pay for the eyeglasses. You say that you would like the Plan to pay the claim. The Plan denied your request. The Plan says the provider is out-of-network with your vision plan.

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 items at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the eyeglasses provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on April 12, 2020.

You asked the Plan to pay for the hearing aids. You say that you should receive all or part of your claim because of the problems caused by Covid-19. The Plan denied your request. The Plan says there are network providers within a reasonable distance.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.

We looked at the file, and the Plan's rules. The provider at issue is not a network provider with the plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on April 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the management services.

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 code 01996 is not supported.

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 01996 is daily hospital management of epidural or subarachnoid continuous drug administration.

We find that CPT code 01996 is not supported in the medical record. Specifically, there is no documentation of daily hospital management of epidural or subarachnoid continuous drug administration. 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 management services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

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 01270 and 36620 are not supported.

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 01270 is anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified. The definition of code 36620 is arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous.

We find that CPT codes 01270 and 36620 are not supported in the medical record. Specifically, there is no documentation of anesthesia for procedures involving arteries of the upper lung, not otherwise specified, to support code 01270. There is no documentation of an arterial catheterization or cannulation for sampling to support code 36620. 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 services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239).

You asked the Plan to pay for discharge day management. You say that the records show that this was performed and was medically necessary. The Plan denied your request. The Plan says this is not documented.

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 99239 is hospital discharge day management; more than 30 minutes.

We find that CPT code 99239 is not supported in the medical record. Specifically, there is not documentation of the time spent on this service. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management.

You asked the Plan to pay for the evaluation and management services. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee and billed under codes 80307 and G0483.

You asked the Plan to pay for this claim. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the claim was billed with an inappropriate place of service code. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided to the enrollee and billed under codes 80307 and G0483.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.

You asked the Plan to pre-approve bone marrow aspiration. You say that bone marrow aspiration is medically necessary. The Plan denied your request. The Plan says bone marrow aspiration is not covered by Medicare.

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 bone marrow aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate. This treatment is not covered by Medicare. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure and services (76942, 88342, 88305, 88313) provided by an out of network (OON) provider.

You asked the Plan to pay for the surgical services. You say that this was a medically necessary procedure. The Plan denied your request. The Plan says this procedure was not urgent or emergent and could have been performed by an in-network provider. The Plan does not cover out of network services except for limited exceptions.

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 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 the surgical procedure and services (76942, 88342, 88305, 88313) provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride.

You asked the Plan to waive the copayment for the ambulance ride. You say that your doctor told you to take an ambulance because it was an emergency. 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 a $225 copayment for each one-way Medicare-covered ground trip.

You have been asked to pay a $225 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services.

You asked the Plan to pay for critical care services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the records do not support the billed service.

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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, this is a time based code and the records do not include the time spent providing the service. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gingival irrigation (D4921 x 4).

You asked the Plan to reimburse you for the gingival irrigation. You say that you have been seeing this provider since you have been a member. You say that this provider is listed on the provider list. You also say that you are allowed 2 dental cleanings per year. The Plan denied your request. The Plan says gingival irrigation 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the gingival irrigation (D4921 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an out of network (OON) provider.

You asked the Plan to pay for skilled nursing services. You say that you rely on the facility to obtain prior authorization. You say that these services are provided with good faith. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the facility. The Plan says that the rendering facility is out-of-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 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 skilled nursing services provided 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 cervical collar.

You asked the Plan to pay for the collar. You say that the records demonstrate medical necessity for the device prescribed. The Plan denied your request. The Plan says the billed code cannot be verified.

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 a valid proof of delivery for the supplies provided in this case. 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 cervical collar.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the set of bitewing x-rays (D0274).

You asked the Plan to pay for the set of bitewing x-rays. You say that the service should be covered. You say that you had coverage on the date of service. You also say that the code is listed as a covered service. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per plan year. The Plan 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, the frequency limit of 1 set of bitewing x-rays per plan year has been exceeded. The record shows that the Plan paid for a set of bitewing x-rays that you received. Therefore, we decided that the Plan does not have to pay for the set of bitewing x-rays (D0274).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 testing provided on July 20, 2020.

You asked the Plan to pay for the COVID-19 testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the COVID-19 testing have not been met. Specifically, there is no evidence that the ordering physician is treating the member. Of note, the ordering physician is located in one state while the member and laboratory are located in a different state. Therefore, we decided that the Plan does not have to pay for the COVID-19 testing provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis (D4355).

You asked the Plan to pay for the dental service. You say that it had been over a year since you had a cleaning due to the pandemic. You say that you had an increased amount of tartar build up on your teeth. You say that your benefit allows up to $2,000 for dental coverage each year. You also say that you feel the service should be covered due to the extenuating circumstances during 2020. The Plan denied your request. The Plan says full mouth debridement to enable a comprehensive oral evaluation and diagnosis 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis (D4355).