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

We decided that the Plan does not have to pay for bronchoscopy, rigid or flexible, including fluoroscopic guidance (31653) provided on December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the bronchoscopy. You say that please kindly review closely per your contract and reconsider for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 bronchoscopy, rigid or flexible, including fluoroscopic guidance (31653) provided on December 28, 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 the therapeutic continuous glucose monitor and supplies provided November 4, 2020.
You asked the Plan to pay for the therapeutic continuous glucose monitor and supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the Plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, there are no medical records which illustrate that the criteria have been met for the therapeutic continuous glucose monitor. 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 therapeutic continuous glucose monitor and supplies provided November 4, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for acute respiratory failure and was discharged home on May 3, 2021. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endovascular revascularization (37225)
provided on December 15, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $250
copayment for outpatient procedures and services including, but not limited to, outpatient surgery performed in
an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $250 copayment for the outpatient procedure provided. 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 endovascular revascularization (37225) provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider from October 7, 2020, to October 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 the services provided to the enrollee by an out-of-network provider from October 7, 2020, to October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on December 3, 2020.
You asked the Plan to pay for the intraoral periapical x-rays and bitewing x-rays. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services are not covered.
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 first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the porcelain crown (D2740) provided on December 17, 2020.
You asked the Plan to reimburse the full amount for the dental service. You say that you received a bill for $775. You say that you had a referral credit of $50 on your account. You say that you only paid $725 of the bill because you had the $50 credit. You also say that you would like to be reimbursed for the credit. The Plan denied your request. The Plan says promotional offers from the provider's office are not eligible for reimbursement. The Plan also says that payment was not made for the "Care to Share" credits and therefore cannot be reimbursed.
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, you cannot be reimbursed for discounts or free promotional offers supplied by your dental provider. The record shows that you did not make any payment of $50 and therefore are not eligible to be reimbursed for it. Therefore, we decided that the Plan does not have to reimburse the full amount for the porcelain crown (D2740) provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services described by current procedural
terminology (CPT) codes 15734 and 14301 provided on June 17, 2020.
You asked the Plan to pay for CPT codes 15734 and 14301. You say that the medical records support the
billing of CPT codes 15734 and 14301. The Plan denied your request. The Plan says the medical records do not
support the billing of CPT codes 15734 and 14301.
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 15734 is Muscle, myocutaneous, or fasciocutaneous flap;
trunk. The CPT Code Manual definition of code 14301 is Adjacent tissue transfer or rearrangement, any area;
defect 30.1 sq cm to 60.0 sq cm.
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 pay for CPT codes 15734 and 14301. Our reviewer
says that the medical records do not support the billing of CPT codes 15734 and 14301. Our physician reviewer
found in this case, the operative note indicates that the fasciocutaneous flap was created from the trapezius and
supra- and infraspinatus muscles. These muscles originate in the neck and shoulder. The elements of CPT
15734 require the donor site to originate in the trunk. The elements of CPT code 15734 are not satisfied. The
operative note indicates that the flap was raised by undermining. No "back-cuts" are described. The described
procedure is a complex closure of a defect left by the excision, not an advancement flap. The elements of CPT
14301 are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT codes 15734 and 14301 have not been met. Therefore, we decided that the
Plan does not have to pay for the surgical services described by current procedural terminology (CPT) codes
15734 and 14301 provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on January 27, 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 this service is not a covered benefit by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on January 27, 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 reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the Plan requires a trial of an oral bisphosphonate drug and zoledronic acid before they will approve the requested drug. Our physician reviewer found in this case, the member has not tried and failed the required drugs. There is no documentation provided indicating that the the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on November
3, 2020.
You asked the Plan to waive the coinsurance for laboratory services. You say that you cannot afford the
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct 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 20%
coinsurance for lab services.
You received laboratory services provided on November 3, 2020. The total allowed amount is $78.21 and 20%
of that is $15.64.
You have been asked to pay the total coinsurance amount of $15.64 for laboratory services. Laboratory
services fall 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 coinsurance for laboratory services provided on November 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for lipid panel test (80061) provided October 27, 2020.
You asked the Plan to pay for the lipid panel test. You say that this was part of your annual wellness visit. Your
doctor told you this was a simple cholesterol check. You expected the plan to pay for the lipid panel. The Plan
denied your request. The Plan says this service exceeds the benefit limitation for the number of cardiovascular
disease testing.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal is a cardiovascular disease screening test and covered by the plan once every
five years. The records show that this service was provided on December 7, 2018, and the plan had paid for this
service on February 11, 2019. Therefore, the benefit has been exhausted. For covered services that have a
benefit limitation, you pay the full cost of any services you get after you have used up your benefit for that type
of covered service. Therefore, we decided that the Plan does not have to pay for lipid panel test (80061)
provided October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services and a device
programming evaluation provided on October 5, 2020.
You asked the Plan to waive the copayments for specialist services and a device programming evaluation. You
say that you never had to pay this much in the past and you disagree with the additional charges. The Plan
denied your request. The Plan says the claims were processed correctly, and you are being charged the correct
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 $35
copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $20
copayment for non-radiological diagnostic services.
You received specialist services on October 5, 2020. Therefore, you are responsible to pay the $35 copayment.
You received a device programming evaluation on October 5, 2020. This is considered a non-radiological
diagnostic service. Therefore, you are responsible to pay the $20 copayment.
The total amount you owe is: $55.
You have been asked to pay the total copayment amount of $55 for specialist services and a device
programming evaluation. Specialist services fall within the physician/practitioner services provided on doctor's
office visits benefit category. A device programming evaluation 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 copayments for
specialist services and a device programming evaluation provided on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 4, 2019.
You asked the Plan to pay for drug tests. You say that the order form indicates the drugs to be tested and
supports the codes billed. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because the documentation submitted does not support the Place of Service (POS) code billed on this
claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing
was taken in an outpatient rehabilitation facility setting, therefore the POS code 11 - indicating an office
setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for
coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug
testing provided on November 4, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation of a chest x-ray provided on September 24, 2020.
You asked the Plan to pay for the chest x-ray interpretation. You say that this was billed correctly with the appropriate modifier being appended to line item 1. Both interpretations are payable. The Plan denied your request. The Plan says that this cannot be paid since payment was already made for this service on another claim.
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's denial states that payment was already made for the global service for a chest x-ray on this date of service. However, the Plan did not furnish any evidence to support this. The Plan also states that payment could be considered if a proper modifier were used. The provider states that this was correctly billed as two x-rays were interpreted on the same date, and that the other line item had the modifier appended. The only documentation submitted shows denial of payment of a single line item for code 71045-26. Without any evidence of the other code that was paid for this same date of service, it cannot be confirmed that a modifier would be required for payment of this claim. Therefore, we decided that the Plan has to pay for the interpretation of a chest x-ray provided on September 24, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and bitewing xrays
provided on October 8, 2020, and November 9, 2020.
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and bitewing x-rays. You say that you
were not aware that you did not have dental coverage under your 2020 benefit package. The Plan denied your
request. The Plan says these codes are dental in nature, which are excluded by Medicare and the plan. The Plan
also says that you do not have preventive or comprehensive dental coverage under your Plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation,
prophylaxis, and bitewing x-rays provided on October 8, 2020, and November 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from June 19, 2020 to August 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that after January 1, 2020, under the Patient-Driven Payment Model, a case-mix adjusted payment for a 30-day period of care is made using one of 432 HHRGs. We looked at the file and Medicare rules. The file shows that the services at issue are for a 60-day plan of care and were not billed correctly. 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 home health services rendered from June 19, 2020 to August 17, 2020.