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

We decided that the Plan does not have to pay for the therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (97530) provided on June 17, 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 insufficient documentation has been provided to corroborate the services provided.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

In this case, the services were provided by an OTA, but the billing provider is a nurse practitioner, non-physician practitioner. Since the billing provider is not an occupational therapist, the OTA cannot provide services under their direction. 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 therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes (97530) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extremity venous duplex scan (93970) provided November 11, 2020.

You asked the Plan to pay for the diagnostic service. You say that as per documentation, the enrollee received venous duplex leg bilateral and arm bilateral. However, 1 unit of 93970 was already adjusted, hence need to bill only 1 unit of CPT 93970 to insurance. Please review for payment. The Plan denied your request. The Plan says the information submitted does not support this many frequencies of services.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 93970 is 1. You billed for 3 units of this code, exceeding the MUE. The plan had made multiple attempts to obtain additional information from the provider. After multiple attempts, none has been received. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for extremity venous duplex scan (93970) provided November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on November 16, 2020.

You asked the Plan to pay for the preventive procedure, comprehensive oral evaluation, and complete series of intraoral x-rays. You say that you asked the provider to only render services that your insurance covered. The Plan denied your request. The Plan says the preventive procedure is not covered. The Plan also says that the comprehensive oral evaluation and complete series of intraoral x-rays exceed the maximum allowed per period.

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, unspecified preventive procedure (D1999) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on October 29, 2018, and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), comprehensive oral evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99204) provided to the enrollee on April 17, 2020, by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99204) provided to the enrollee on April 17, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) provided February 3, 2021.

You asked the Plan to pay for the additional intraoral x-ray. You say that you received services from a network provider, and they should be covered. The Plan denied your request. The Plan says the claims from this date of service have been reprocessed as in-network however, only one intraoral x-ray is covered per year and therefore the second x-ray is 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. The Plan covers one intraoral x-ray per calendar year.

We looked at this the file and Medicare rules. The Plan has covered on intraoral x-ray on the same date of service. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230) provided February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 7, 2021.

You asked the Plan to pay for the laboratory services. You say that the patient's healthcare provider took the specimens at their office and sent them to the laboratory for analysis. You say that you request the claim be considered for payment as the service was referred by an authorized provider. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 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 laboratory services provided by an out-of-network provider on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 88104 provided on November 30, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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.

We find that CPT codes 88361, 88312, 88305, and 88104 are not supported in the medical record. Specifically, these codes have a Physician Fee Schedule PCTC indicator of "1" and the claim was billed with Place of Service 22 - Outpatient Hospital. The professional interpretation was furnished in a different payment locality from where the Technical Component was furnished. We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be billed separately billed with modifier - 26 by the interpreting physician.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 88104 provided on November 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 19, 2021.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

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 January 19, 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 the ambulance services provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical services provided on January 5,
2021, through January 26, 2021.

You asked the Plan to waive the copayment for the medical services. You say that you believe you should have
to pay a copayment because you believed the provider was a primary care physician and there would be no
copayment for the office visit. The Plan denied your request. The Plan says you sought services from a
specialist.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received specialist office services (Current Procedural Terminology (CPT) code 99204) on January 5, 2021. You were asked to pay a $50 copayment for the specialist visit. On January 25, 2021, you received ultrasound study of arteries and arterial grafts of both legs (CPT code 93925), ultrasound scan of vena cava or groin graft or vessel blood flow (CPT code 93978), and ultrasound study of arteries of both arms and legs (CPT code 93922). You were asked to pay a $100 copayment for the testing. Furthermore, you received specialist office services (CPT code 99213) on January 26, 2021. You were asked to pay a $50 copayment for the specialist services. Your 2021 EOC states that enrollees must pay a $100 copayment for Medicare-covered computed tomography (CT) Scans, Vascular Studies and Breathing Capacity Tests and enrollees must pay a $50 copayment for each specialist visit for Medicare-covered services. 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 medical services provided on January 5, 2021, through January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on January 4, 2021.

You asked the Plan to waive the copayment for an x-ray. You say that this was a post-op appointment. You say that this should be covered. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $50 copayment for outpatient diagnostic tests/x-ray.

You have been asked to pay $49.18 which is less than your copayment amount of $50 for an x-ray. The correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/x-ray benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings and unspecified preventive service provided on December 29, 2020.

You asked the Plan to pay for the dental services. You say that you were advised that out of network services would be covered with a 60/40 coinsurance. You also say that you do not understand why this service was denied for out of network. The Plan denied your request. The Plan says the provider in this case does not participate with the Plan. The Plan also says that supplemental dental services must be performed by a participating provider in order to be 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, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings and unspecified preventive service provided on December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic shoes (A5500) and inserts (A5512) provided on November 18, 2020.

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for these items for the 2020 calendar year.

Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

The record shows that you have previously received diabetic shoes and inserts on January 18, 2020. The Plan issued payment to the provider of service for these items on January 24, 2020. The Plan contract states that one pair per calendar year of therapeutic custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts are covered. You have exhausted the allowable benefit for these items for the 2020 calendar year. Therefore, we decided that the Plan does not have to pay for the diabetic shoes (A5500) and inserts (A5512) provided on November 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided from October 21, 2020, to October 22, 2020.

You asked the Plan to waive the copayment for emergency care. You say that you received a letter stating that all services were fully covered in 2020. 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 $120 copayment for emergency care. 

You received emergency care from October 21, 2020, to October 22, 2020. Emergency care is not included in the COVID-19 copayment waiver. Therefore, you are responsible to pay the $120 copayment.

You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided from October 21, 2020, to October 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for measurement of proteins associated with prostate cancer (CPT code 81539) provided to the enrollee on September 24, 2020.
You asked the Plan to pay for the laboratory services. You say that the services were necessary. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. This is a non-coverage policy for the 4Kscore assay. This test is a laboratory developed test (LDT) and has not undergone Food and Drug Administration (FDA) review or scrutiny. Therefore, we decided that the Plan does not have to pay for measurement of proteins associated with prostate cancer (CPT code 81539) provided to the enrollee on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99213) provided to the enrollee on February 20, 2020, by an out-of-network provider.

You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, and the services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office services (CPT code 99213) provided to the enrollee on February 20, 2020, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture, comprehensive metabolic panel, urinalysis, hemoglobin A1C level, complete blood count, prothrombin time, PTT, culture screen, and urine bacteria culture provided on June 23, 2020.

You asked the Plan to pay for the routine venipuncture, comprehensive metabolic panel, urinalysis, hemoglobin A1C level, complete blood count, prothrombin time, PTT, culture screen, and urine bacteria culture. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the routine venipuncture, comprehensive metabolic panel, urinalysis, hemoglobin A1C level, complete blood count, prothrombin time, PTT, culture screen, and urine bacteria culture provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on April 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that your physician provided medically necessary services in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. 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 the domiciliary or rest home visit (99336) provided on April 8, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on January 15, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you declined the medication that was offered in the recovery room. The Plan denied your request. The Plan says the self-administered drugs are not covered.

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 pay for the self-administered drugs provided on January 15, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.