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

We decided that the Plan does not have to pay for the x-ray exam of the hip (73502), the set-up of portable
x-ray equipment (Q0092), and the transportation of portal x-ray equipment (R0070) rendered by the OON
provider on December 5, 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 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 x-ray exam of the hip (73502), the set-up of portable x-ray equipment
(Q0092), and the transportation of portal x-ray equipment (R0070) rendered by the OON provider on
December 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to be reimbursed for an exercise bike provided on August 13, 2020.

You asked the Plan to reimburse you for the exercise bike. You say that you were told the exercise bike would be denied, but then a few weeks later, you received a notification that the fitness equipment reimbursement was going to be implemented temporarily. The Plan denied your request. The Plan says the exercise bike was not a covered benefit at the time of purchase.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan's rules for coverage of gym benefits have not been met because the fitness equipment reimbursement was not a covered benefit on the date you purchased the bike. Therefore, we decided that the Plan does not have to be reimbursed for an exercise bike provided on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve scaling and root planing for the upper left quadrant. We decided that the Plan does not have to pre-approve scaling and root planing for the upper right, lower right, and lower left quadrants.
You asked the Plan to pre-approve scaling and root planing for all 4 quadrants. You say that the scaling and root planing is medically necessary. The Plan denied your request. The Plan says scaling and root planing is covered once per 3 years, per quadrant. The Plan also says that the frequency limit has been reached.
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 decided that the Plan has to pre-approve scaling and root planing for the upper left quadrant.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the scaling and root planing for the upper left quadrant have not been met. The file does not show that the Plan has paid for this service for the upper left quadrant in the last 3 years. Therefore, we decided that the Plan has to pre-approve scaling and root planing for the upper left quadrant.
We also decided that the Plan does not have to pre-approve scaling and root planing for the upper right, lower right, and lower left quadrants.
We looked at 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. Specifically, the file shows that the frequency limit has been reached. The file shows that the Plan paid for scaling and root planing for the upper right and lower right quadrants that you received on December 1, 2021. The file also shows that the Plan paid for scaling and root planing for the lower left quadrant that you received on December 4, 2021. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing for the upper right, lower right, and lower left quadrants.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for a cardiovascular risk assessment laboratory test provided to the enrollee
on January 18, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says that based on the Medicare Local Coverage Article: Billing and Coding: MolDX:
Biomarkers in Cardiovascular Risk Assessment (A57559), and the Medicare Local Coverage Determination
(LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523), this testing is not covered by
Medicare.
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. We find the Medicare regulations referenced by the Plan are not in the Florida MAC B jurisdiction
for coverage and therefore do not apply. The Plan has not substantiated its denial. The medical records clearly
outline how this testing will be used to treat the enrollee; therefore, medical necessity has been established.
Therefore, we decided that the Plan has to pay for a cardiovascular risk assessment laboratory test provided to
the enrollee on January 18, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a flexible outer surface protective covering and socket insert for a prosthetic.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that replacement durable medical equipment (DME) is covered in cases of irreparable damage or exceeding the reasonable lifetime period of five years. We looked at the file and Medicare rules. The file shows that your current prosthetic socket includes an
alignable system that is not damaged beyond repair or more than five years old. The requested items are not
covered, as the current equipment does not need to be replaced. Therefore, we decided that the Plan does not
have to pre-approve a flexible outer surface protective covering and socket insert for a prosthetic.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 4, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for patients with suspected or documented cardiovascular disease.
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 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 is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (99203) and acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810).
You asked the Plan to pre-approve acupuncture services. You say that you have been told by the insurance that the enrollee would be covered. Acupuncture may help stimulate muscle and blood flow on his left side. The Plan denied your request. The Plan says acupuncture for the treatment of cerebrovascular accident/stroke is not a plan supplemental benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, acupuncture is only covered for the treatment of
chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve the office visit
(99203) and acupuncture, one or more needles, without electrical stimulation, initial 15 minutes (97810).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azithromycin.
You asked the Plan to pre-approve Azithromycin. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Azithromycin.
Benefits for Azithromycin 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-height adjustable joystick receiver mount identified with code K0108.
You asked the Plan to pre-approve a non-height adjustable joystick receiver mount. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for certain indications. Code K0108 must not be used for items that are already part of items that have a specific code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-height adjustable joystick receiver mount have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-height adjustable joystick receiver mount identified with code K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the remote monitoring of a wireless pulmonary artery pressure sensor (93264) rendered by the out-of-network (OON) provider on April 8, 2021.
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 the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the remote monitoring of a wireless pulmonary artery pressure sensor (93264) rendered by the out-of-network (OON) provider on April 8, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 4, 2020 and billed under code 57185-26.
You asked the Plan to pay this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says while a portion of this claim was paid, there are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive procedure code that describes the services performed. Physicians must avoid upcoding. The Plan states that procedure code 51785-26 is not supported by the medical records submitted. The technical report did not include documentation of needle electromyography studies (EMG) of anal or urethral sphincter, using any technique; therefore, this code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. The services provided must be substantiated by the medical records. In this case, the records provided do not clearly support the billing of code 57185. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from November 27, 2020, to November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this claim was billed with an inappropriate HIPPS code.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The 2020 CMS HIPPS code master list does not list HIPPS code 2AFLT as a valid code. This code was only valid through December 2019. 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 services provided from November 27, 2020, to November 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) (D0367) and surgical placement of implant body (D6010 x 4).
You asked the Plan to pre-approve the dental services. You say that you received a denial for implants. You say that you have a $5,000 Dental Waiver. You also say that your dental plan advised you could use the waiver for implants. The Plan denied your request. The Plan says cone beam CT is not listed as a covered service. The Plan says that surgical placement of implant body is not listed as a covered service either.
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 cone beam CT and implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) (D0367) and surgical placement of implant body (D6010 x 4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on March 3, 2021, and March 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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, the records provided do not show that 30-74 minutes of critical care services were provided on the dates of service in question.
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 critical care services (99291) provided on March 3, 2021, and March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 1, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 HCPCS codes must be submitted for the panel. We looked at the file and Medicare rules. The requested lab panel was billed with multiple codes. Per A57910, this panel must be billed with one HCPCS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the lab services (87426) provided on December 2, 2020, and December 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not a valid code.
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. 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 argues that code 87426 is not a valid code. However, this code is payable under the Clinical Laboratory Fee Schedule. The Plan has not provider documentation supporting code 87426 as an invalid code. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services (87426) provided on December 2, 2020, and December 17, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 29, 2020.
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. The Plan states the laboratory results submitted indicate the specimen was collected on December 29, 2020 and received by the laboratory on December 30, 2020.
The Plan notes the enrollee resides in Texans and the billing laboratory is in New Jersey. Therefore, the billed code cannot be verified.
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 this claim cannot be paid as billed due to an issue with the place of service code. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 29, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care from August 10, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a SNF setting beyond the last covered date. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care from August 10, 2021, forward.