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

We decided that the Plan does not have to pay for laboratory services (81479) provided on December 24, 2020
by an out-of-network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this is a covered service. The Plan denied
your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services (81479) provided on December 24, 2020 by
an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax (S9999) for items purchased May 4, 2021.

You asked the Plan to pay for sales tax. You say that you have followed all recommendations from your doctor,
physical therapists and heart doctor and have ordered all necessary equipment ordered by your doctors and
physical therapists. The Plan denied your request. The Plan says Medicare does not reimburse separately for
sales tax.

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, we have confirmed that sales tax
cannot be paid separately as it is included in the base price of the DME item.

Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan
does not have to pay for sales tax (S9999) for items purchased May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for sclerosant injections (36471) provided on January 15, 2021.
You asked the Plan to pay for sclerosant injections. You say that this is supported by the records. The Plan denied your request. The Plan says the records do not show that this was medically necessary.
The Plan must follow Medicare rules. Medicare rules say that invasive procedures for the treatment of varicose veins are considered medically reasonable and necessary when an evaluation of the patient has been performed including a history and physical examination, the CEAP clinical classification and the revised Venous Clinical Severity Score (VCSS), a duplex scan of the deep and superficial venous systems supports the examination findings, and the documentation supports signs and/or symptoms that interfere with activities of daily living and/or quality of life.
We looked at the file and Medicare rules. The submitted medical records do not include any documentation of a patient evaluation or duplex scans. Without this information, the medical necessity of the services at issue cannot be verified. Based on this information, we decided that Medicare rules for coverage of sclerosant injections have not been met. Therefore, we decided that the Plan does not have to pay for sclerosant injections (36471) provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on April 22, 2021.

You asked the Plan to reduce the copayment for the urgent care visit. You say that you were told your copayment was $10 and not $45. You should not be responsible for the remaining balance. 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 $45 copayment for each covered office visit to other providers for urgently needed services.

You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen at an urgent care center. 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 reduce the copayment for the urgent care visit provided on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 3, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment
may be made only if the physician interprets an abnormal smear for hospital inpatient.
We looked at the file and Medicare rules. Billed procedure code 85060 (blood smear interpretation) has a
PC/TC indicator of 8 and the file shows that the services were performed in the inpatient hospital setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 3,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on April 28, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the claim processed and paid with the correct full eyewear allowance of $400.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 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 file shows that the Plan processed and paid the claim with the
correct full eyewear allowance of $400. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on April 28, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided from January 5, 2021, to January 26, 2021 by a licensed social worker.
You asked the Plan to pay for these services. You say that you believe these services should be covered by the Plan. The Plan denied your request. The Plan says these services were not rendered by a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for services provided by a practitioner who is not a Medicare eligible provider. Your provided was a licensed social worker. This is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided from January 5, 2021, to January 26, 2021 by a licensed social worker.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CardioPro genetic testing (81291, 81439) provided on June 29, 2020.

You asked the Plan to pay for CardioPro genetic testing. You say that this is a covered service. The Plan denied your request. The Plan says this testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of CardioPro genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for CardioPro genetic testing (81291, 81439) provided on June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic dental x-rays (D0150, D0330) provided April 22,
2021.
You asked the Plan to pay for the panoramic dental x-rays. You say that the services were medically necessary.
The Plan denied your request. The Plan says this is not a covered benefit under your dental plan.
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
panoramic dental x-rays (D0150, D0330) provided April 22, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on March 29, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physical therapy services. 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 physical therapy services provided on
March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing, one to three teeth per quadrant (D4342) gingival irrigation per quadrant (D4921) periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided April 7, 2021.
You asked the Plan to pay for the dental services. You say that you are appealing the decision of nonpayment of this claim. If you had been informed of this before hand you would have asked the periodontist to wait until July 19, 2021. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's contract says that periodontal scaling and root planing is covers one procedure per quadrant every 3 calendar years. The records show that this benefit was last used on April 18, 2019. There is no coverage for adjustment partial denture-
mandibular, and gingival irrigation - per quadrant services. 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 periodontal scaling and root planing, one to three teeth per quadrant (D4342) gingival irrigation per quadrant (D4921) periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine provided on May 11, 2021.
You asked the Plan to pay for a shingles vaccine under Medicare Part B. You say that if you thought it was not covered you would not have had the vaccine. The Plan denied your request. The Plan says the shingles vaccine is not covered under Medicare Part B.
The Plan follows Medicare rules. Medicare does not pay for or provide a shingles vaccine under Medicare Part B. The Plan contract states the shingles vaccine is not covered under Medicare Part B. This claim should be submitted to your Medicare Part D carrier. Therefore, we decided that the Plan does not have to pay for a shingles vaccine provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0274, D4910, D0150) provided February 6, 2020 to October 27, 2020.

You asked the Plan to pay for dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says the dentist at issue has opted out of the Medicare program and is not eligible for payment.

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 pay for dental services (D0274, D4910, D0150) provided February 6, 2020 to October 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided the Plan does not have to pay for home health services provided to the enrollee on January 6, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says that the claim was billed with an invalid type of bill code for a non-participating home health provider. The Plan states a corrected claim would be reviewed.
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 was submitted with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee on January 6, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided from April 2, 2021, to May 21, 2021.

You asked the Plan to pay for these services. You say that you were told these services should be covered. The Plan denied your request. The Plan says outpatient mental health services must be rendered by Medicare eligible providers.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for services provided by a practitioner who is not a Medicare eligible provider. Your provided was a licensed social worker. This is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided from April 2, 2021, to May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would benefit from admission to an IRF. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting. Your medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on March 4, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on March 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 27, 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 code 51785 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 51785 is needle electromyography studies (EMG) of anal or urethral sphincter, any technique. 

We find that CPT code 51785 is not supported in the medical record. Specifically, there is no documentation of needle electromyography studies of the anal or urethral sphincter. 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 November 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from January 5, 2021 to January 7, 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 services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. 
We looked at the file and Medicare rules. The file shows that the home health services were not billed with the required 032x TOB code. Therefore, we decided that the Plan does not have to pay for the home health services rendered from January 5, 2021 to January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp (A9270).

You asked the Plan to pre-approve the ramp. You say that this is medically necessary. The Plan denied your request. The Plan says there is no in-home need for this ramp.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies (K0553) provided on March 26, 2021.
You asked the Plan to pay for the diabetic supplies. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 diabetic supplies (K0553) provided on March 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0998) provided April 24, 2021.

You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. You requested only a paramedic, but an ambulance came as well. The Plan denied your request. The Plan says ambulance services without transportation are not covered.

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 April 24, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services (A0998) provided April 24, 2021.