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

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram (G0279,
77066).

You asked the Plan to waive the copayment for the mammography services. You say that you have never been
charged for this service before. The Plan denied your request. The Plan says you had a diagnostic mammogram
(77066) and a diagnostic breast tomosynthesis (G0279). Both services are subject to a $20 copayment.

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 $20
copayment for diagnostic x-rays and ultrasounds.

You have been asked to pay a $40 total copayment for two diagnostic mammogram services: a diagnostic
mammogram and a diagnostic breast tomosynthesis. In this case, the services were billed as a diagnostic
mammogram rather than a screening. A service, such as a mammogram, is considered diagnostic when it is
provided to investigate to a specific concern. A screening mammogram is covered under your Plan once every
twelve months and is provided as a routine check when there are no symptoms present.

You were provided with diagnostic mammography services, which fall within the diagnostic x-rays and
ultrasounds 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 the diagnostic
mammogram (G0279, 77066).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307 and G0483).

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim form submitted indicates that the laboratory specimen was obtained in a laboratory, but the submitted medical documentation indicates that the specimen was obtained in an office setting.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 80307 and G0483 is not supported in the record. Specifically, the claim indicates that the specimen was collected in the laboratory, but the documentation submitted indicates that the face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307 and G0483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0220, D0230).

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this is not a
covered benefit.

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 services are not among
those covered under this benefit. The Plan covers only those dental services for which the codes are listed in
the Evidence of Coverage. Dental codes D0220 and D0230 are not listed, and therefore are not covered.
Therefore, we decided that the Plan does not have to pay for the dental services (D0220, D0230).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (82947, 84520, 85014,
86003, 82040, 8204382247, 82310, 82374, 82435, 82565, 82570, 84075, 84132, 84155, 84295, 84450, 84460,
85025, 86601, 80050, 83036, 86141, 82728, 84403, 82306, 83880, 84443).

You asked the Plan to pay for cardiovascular risk assessment testing. You say that this should be covered. The
Plan denied your request. The Plan says this was billed with diagnosis code Z82.49 for a family history of
ischemic heart disease and other diseases of the circulatory system, indicating this was a screening service.

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, cardiovascular risk assessment testing, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for cardiovascular risk assessment testing (82947, 84520, 85014, 86003, 82040,
8204382247, 82310, 82374, 82435, 82565, 82570, 84075, 84132, 84155, 84295, 84450, 84460, 85025, 86601,
80050, 83036, 86141, 82728, 84403, 82306, 83880, 84443).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this testing was medically necessary and requested by an in-network provider. The Plan denied your request. The Plan says to report a CGP, service providers should use CPT code 81479 (used for the entirebundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in thecomment/narrative field for the test; not unbundled to separate codes.

The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report Guardant360 testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for F1Heme testing (81455).

You asked the Plan to pay for the F1Heme testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this testing has not been billed correctly.

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 code 81455 is not supported in the record. Specifically, CGP testing should use CPT code 81479 in addition to the approved DEX Z-CodeTM. Based on this information, we decided that Medicare rules for coverage of the F1Heme testing have not been met. Therefore, we decided that the Plan does not have to pay for F1Heme testing (81455).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound, breast, unilateral, real time
with image documentation, including axilla when performed; complete (76641).

You asked the Plan to waive the copayment for an ultrasound of the breast. You say that it has been too long
since the ultrasound was done, and you should not be charged for it. The Plan denied your request. The Plan
says the copay was applied correctly.

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 $100
copayment for outpatient diagnostic testing.

You have been asked to pay a $100 copayment for an ultrasound of the breast. An ultrasound of the breast falls
within the outpatient diagnostic testing 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 ultrasound, breast, unilateral, real time with image documentation, including axilla when performed;
complete (76641).

Your complaint about the length of time between the service and the charge is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture relining.

You asked the Plan to pay for the denture relining. The Plan denied your request. The Plan says this is not a
covered benefit.

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 services are not among
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage.
Denture relining is not covered. Therefore, we decided that the Plan does not have to pay for the denture
relining.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99239).

You asked the Plan to pay for discharge day management services. You say that the medical records provided will show proof of medical necessity. 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 member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs taken.

You asked the Plan to pay for the self-administered drugs taken during the emergency room visit. You say that
you would like this bill paid. The Plan denied your request. The Plan says self-administered drugs while in
outpatient status are not covered but they reduced your bill.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 taken.

Benefits for the self-administered drugs taken during the emergency room visit may be available under
Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any
benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction.

You asked the Plan to pay for the refraction. You say that you did not need a refraction and could have done it
yourself. The Plan denied your request. The Plan says this is not a covered benefit.

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 or eyewear. Therefore, we
decided that the Plan does not have to pay for the eye refraction.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular re-education (97112) and manual therapy
(97140) provided on July 23, 2020.

You asked the Plan to pay for the neuromuscular re-education and manual therapy. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted does not show that more than eight minutes of CPT codes 97112 and 97140 were provided on the
billed date of service.

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 97112 and 97140 are not supported in the record. Specifically, the documentation
submitted does not indicate that more than eight minutes of neuromuscular re-education and manual therapy
services were rendered. Of note, the record does not include the amount of time spent providing these services.
Based on this information, we decided that Medicare rules for coverage of the neuromuscular re-education and
manual therapy have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular
re-education (97112) and manual therapy (97140) provided on July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee.

You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says the 100-day SNF benefit has been exhausted.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the
enrollee.

You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says then 100-day benefit
limit has been exhausted.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone sixty days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when she has not
been receiving care in a hospital or skilled care in a SNF for at least sixty days in a row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs taken.

You asked the Plan to pay for the self-administered drugs taken while in outpatient status. You say that you didn't have access to your own medications. The Plan denied your request. The Plan says the drugs are not covered under your Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs taken.

Benefits for the self-administered drugs taken while in outpatient status may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0140).

You asked the Plan to pay for the oral exam. The Plan denied your request. The Plan says this is only covered once per year.

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 services are subject to a benefit limitation. The Plan covers code D0140 once per year. The records show that the Plan processed and paid for code D0140. The requested exam exceeds the benefit and is not covered. Therefore, we decided that the Plan does not have to pay for the oral exam (D0140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says you are responsible for payment.

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 services are subject to a higher cost share when provided by an out-of-network provider. You were provided an exam and x-rays by an out-of-network provider. The Plan rules say that you may be billed by the out-of-network provider for any amount greater than the maximum allowable charge. In this case, the billed amount exceeds the maximum allowable charge by $55 for these services, so you are responsible for that amount. Additionally, the Plan only covers those services listed in the Evidence of Coverage. Dental code D4346 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87491, 87591).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says these tests were screening tests and are not covered.

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 tests at issue in this appeal were requested solely for screening purposes. No clinical documentation was
provided to support the tests were medically necessary. Medicare does not cover this test solely for screening
purposes. Therefore, we decided that the Plan does not have to pay for lab services (87491, 87591).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that the enrollee needs more care than what you can provide. The Plan denied your request. The Plan says the enrollee has no daily therapy or nursing needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a minimal assist to modified independent level with functional mobility. He required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services.

You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 853 is defined as infectious and parasitic diseases with O.R. procedure with MCC.

In this case, you billed the services provided with DRG 853. 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 the inpatient services. Our reviewer says that the documentation does not support that DRG code billed. Our physician reviewer found the enrollee was admitted to the hospital with a necrotic ulcer on the right foot. There was evidence of sepsis and the enrollee was treated with IV antibiotics. The enrollee was evaluated by Podiatry and Infectious Disease. The enrollee received treatment for diabetes, hypertension, chronic kidney disease and congestive heart failure. The documentation does not substantiate the use of DRG 853.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 853. We note that the plan has paid this claim with DRG 854, which our reviewer has found to be more accurate. Therefore, we decided that the Plan does not have to pay for the inpatient services.