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

We decided that the Plan does not have to pay forCPT codes J0585, 64616, and 99215-24 provided on May 14, 2019.You asked the Plan to pay forCPT codes J0585, 64616, and 99215-24. 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. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 300 units of CPT code J0585 are not supported in themedical record. The medical record does not state how many unitsof CPT code J0585were provided. Based on this information, we decided that Medicarerules for coverage of CPT codeJ0585hasnot been met.
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 64616 is Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis). We find that CPT code 64616 is not supported in the medical record. Specifically, the procedure note submitted does not indicate the specific muscles and/or nerves injected.Based on this information, we decided that Medicare rules for coverage of CPT code 64616 have not been met.The rules say visits by the same physician on the same day as a minor surgery are included in the payment for the procedure. The records show that the enrollee received a minor surgical procedure witha 10-day global period and the initial visit was performed by the same physician on the same day as the minor surgical procedure. The records do not show that a significant and separately identifiable service was also performed. Based on this information,we decided that Medicare rules for coverage of CPT code 99215-24 have not been met.Therefore, we decided that the Plan does not have to pay forCPT codes J0585, 64616, and 99215-24 provided on May 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist-hand orthoses (L3916) provided to the enrollee on March 14, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say 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 enrollee's medical record does not corroborate the dispensing order. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for wrist-hand orthoses (L3916) provided to the enrollee on March 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for adjacent tissue transfer services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
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 the denied codes is: CPT 14301: Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. CPT 14302: Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT codes 14301 and 14302 are not supported by the medical record. According to CPT rules, the tissue transfers mentioned in the operative report can be reported with more specific CPT codes indicating the site of the flap/tissue transfer. We looked at this coder's review, the file, and Medicare rules. 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 adjacent tissue transfer services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound therapy (97035), manual therapy (97140), and the electrical stimulation (97032) provided on May 15, 2019.
You asked the Plan to pay for the ultrasound therapy, manual therapy, and the electrical stimulation. You say that you are requesting a reconsideration of the plan's denial. The Plan denied your request. The Plan says the services provided are not a covered benefit under the member's policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the ultrasound therapy (97035), manual therapy (97140), and the electrical stimulation (97032) provided on May 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization services provided on March 16, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the requested service code is not substantiated by the clinical documentation in the medical records submitted for review.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 37231 is "Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed."We asked our codingreviewer 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our codngreviewer found CPT code 37231 is not supported. The record does not contain evidence that an arthrectomy and stent placement was performed on a peroneal artery during this episode of care.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service provided on March 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused detailed and extensive oral evaluation and panoramic x-ray provided on August 26, 2019.
You asked the Plan to pay for the problem focused detailed and extensive oral evaluation and panoramic x-ray. You say that your medical doctor sent you to this oral surgery center because you were having jaw pain. You also say that you thought this was medical and not dental. The Plan denied your request. The Plan says the problem focused detailed and extensive oral evaluation is not a covered service under your 2019 benefits. The Plan also says that you have reached your benefit allowance for panoramic x-rays.
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 problem focused detailed and extensive oral evaluation is not among those covered under this benefit. Also, panoramic x-rays are limited to one procedure every three years. The record shows that you received a panoramic x-ray on March 8, 2018 and your panoramic x-ray benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused detailed and extensive oral evaluation and panoramic x-ray provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673). You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0673) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral ankle foot orthoses (L1971) provided on April 2, 2019.You asked the Plan to pay for the bilateral ankle foot orthoses. You say that you are requesting reconsideration of the plan's denial as the orthotic devices were prescribed as adjunctive therapy to assist in reducing the level of pain the member is experiencing and for the overall improvement in the patient's quality of life.The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. Review of the claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay for the bilateral ankle foot orthoses (L1971) provided on April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0673) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe manual therapy (97140) provided onApril 24, 2019.You asked the Plan to pay forthe manual therapy services. You say that you are requesting reconsideration of the plan's denial.The Plan denied your request. The Plan says these services are not a covered benefit under the member's policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the manual therapy (97140) provided onApril 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on July 24, 2017.You asked the Plan to pay foroffice visit. You say that the enrollee's primary insurance coverage was not effective until June 1, 2018, therefore the Plan is responsible for payment.The Plandenied your request. The Plan says the denial of payment for this service is correct, because the Plan is the enrollee's secondary payer for this date of service and cannot process this claim until the primary insurance carrier Explanation of Benefits (EOB) is received.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to submit this claim to the enrollee's primary insurance carrier and obtain the primary insurance Explanation of Benefits (EOB) to allow processing by the Plan. As the secondary insurer, the Plan cannot be held responsible for office visit until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay foran office visit provided on July 24, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an ophthalmological medical examination and evaluation provided on June 18, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 Plandidnot pre-approve the services at issue. We found no exception that would require the Plan to pay for theseservices. Therefore, we decided that the Plan does not have to pay for physician's services for an ophthalmological medical examination and evaluation provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe hyaluronan injections provided on August 12, 2019.You asked the Plan to waive the coinsurance forthe hyaluronan injections. You say that you were not aware of the coinsurance. You say that you cannot afford this amount.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrolleesin 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 each Medicare-covered Part B drug. You have been asked to pay $211.20, which is 20% of the allowed amount for each injection. The allowed amount is $1,056 (20% x $1,056 = $211.20). The total amount you owe is $422.40 ($211/injection x 2 injections = $422.40). The hyaluronan injections falls within the "Medicare Part B prescription drugs" 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 thatthe Plan does not have to waive the coinsurance forthe hyaluronan injections provided on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tissue exam by a pathologist provided on July 22, 2019 by the out of network provider.You asked the Plan to pay forthe laboratory service. You say that the referring provider is responsible for obtaining the necessary authorization. You say that the claim should be linked to the existing precertification or authorization in your system, or the paid facility claim.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.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 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 forthetissue exam by a pathologist provided on July 22, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing provided on May 27, 2019.You asked the Plan to pay forgenetic tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare-prohibited action.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forgenetic testing provided on May 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98941) provided on July 31, 2019.You asked the Plan to pay forthese services. You say that you are an in-network provider with the health plan, therefore, the services should be covered.The Plan denied your request. The Plan says theservices were rendered by a non-network provider who does not work with the member's health plan.The member's primary care provider did not refer for theseservices. The healthplan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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.You arenot a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forthe chiropractic manipulative treatment (98941) provided on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite, two surfaces-posterior (D2392) provided on July 23, 2019.You asked the Plan to pay for these services. You say that your old amalgam filling broke off leaving a gaping hole in your tooth. Additionally, you say the repair of this tooth was necessary for the stability of the partial. ThePlan denied your request. The Plan says the dental services provided are not a covered benefit under your policy.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 services provided are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the resin-based composite, two surfaces-posterior (D2392) provided on July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 15, 2019 by out of network provider, "the doctor" .You asked the Plan to pay foroutpatient lab work. You say that you would like to have this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question. The Plan says that the referring provider is also out-of-network.Medicare rules say that plans can require enrollees to get care fromnetwork 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 has network providers available who can provide 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 forthe medical services provided on July 15, 2019 by out of network provider, "the doctor".