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

We decided that the Plan does not have to waive the copayments for the Interrogation device evaluations (93295, 93297) provided June 2, 2020, August 3, 2020, and August 17, 2020.
You asked the Plan to waive the copayments for the Interrogation device evaluations. You say that you believe you should be charged $0 copayments for home health care agency services. The Plan denied your request. The Plan says the copayments were 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 $25 copayment for Medicare-covered non-radiological diagnostic services. You have been asked to pay a total of $75 ($25 copayment x 3 services) for the Interrogation device evaluations. This service 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 the Interrogation device evaluations (93295, 93297) provided June 2, 2020, August 3, 2020, and August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival flap procedure (D4241), the bone replacement graft (D4263), and the biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on October 13, 2020.
You asked the Plan to pay for the dental services. You say that you were not able to go to an approved dentist due to Covid-19. You say that you live in an area where very few dentists handle issues such as yours. You say that you needed to have these services done due to pain and infection. You say that you were advised on the phone that there would be some coverage. You also say that you will cancel your plan if it will not benefit you. The Plan denied your request. The Plan says the dental services you received are not listed as covered service. The Plan also says that any services that are not listed 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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the gingival flap procedure (D4241), the bone replacement graft (D4263), and the biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an unlisted arthroscopy procedure provided on June 26, 2020.
You asked the Plan to pay for the unlisted arthroscopy procedure. You say that a capsular plication of knee procedure was done and there is no procedure code for it. The Plan denied your request. The Plan says the operative report did not include documentation of an arthroscopic unlisted procedure therefore the code cannot be verified.
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 29999 is Unlisted procedure, arthroscopy. We find that CPT code 29999 is not supported in the medical record. Specifically, the requested procedure code is not substantiated by the clinical documentation and therefore is not payable. Based on this information, we decided that Medicare rules for coverage of the unlisted arthroscopy procedure have not been met. Therefore, we decided that the Plan does not have to pay for an unlisted arthroscopy procedure provided on June 26, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 11, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99284 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99284 is Level 4 emergency department visit for evaluation and management of patient with problem of high severity, including detailed history and physical examination, and medical decision-making of moderate complexity. We find that CPT code 99284 is not supported in the medical record. Specifically, the records do not support a Level 4 emergency department visit. 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 emergency room (ER) services rendered on June 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 27, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you cannot afford the copayment. The Plan denied your request. The Plan says the copayment 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 $100 per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $100 copayment for the MRI. The MRI 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 copayment for the MRI provided on October 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the x-ray provided on July 1, 2020 and laboratory tests provided on July 29, 2020.
You asked the Plan to waive the deductible for the x-ray and laboratory tests. You say that your policy started July 1, 2020 so the bills should be paid. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a deductible amount of $198 for Medicare Part B services. Until you have paid the deductible amount, you must pay the full cost for Medicare Part B services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the $198 deductible applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the x-ray and laboratory tests were received. Therefore, we decided that the Plan does not have to waive the deductible for the x-ray provided on July 1, 2020 and laboratory tests provided on July 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (47563) provided January 23, 2020.
You asked the Plan to pay for the surgical services. You say that these services were medically necessary. The Plan denied your request. The Plan says the type of surgical assistant used during the procedure is not eligible for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (47563) provided January 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6241, D6751) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the case did not demonstrate any evidence of an existing medical condition or special needs to meet criteria for approval.
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 the services when the services are medically necessary and reasonable. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there was no documentation supporting the need for a fixed bridge replacing posterior tooth #19 in this case rather than a removable appliance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D6241, D6751) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Nerve Conduction study (95886) provided August 7, 2020.
You asked the Plan to pay for the Nerve Conduction study. You say that the services were medically necessary. 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 the actual number of units provided for each procedure code. We find that 2 units of CPT code 95886 are not supported in the medical record. The medical record only supports 1 unit of CPT code 95886. Based on this information, we decided that Medicare rules for coverage of the Nerve Conduction study have not been met. Therefore, we decided that the Plan does not have to pay for a Nerve Conduction study (95886) provided August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from January 2, 2020, through June 30, 2020.
You asked the Plan to waive the coinsurance for dialysis. You say that you were not informed she had to pay 20% coinsurance. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare-covered dialysis services. The enrollee has been asked to pay a total of $3,780.77 for dialysis.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
January 1, 2020-January 30, 2020
Dialysis
$3,223.87
20%
$644.80
February 1, 2020-February 29, 2020
Dialysis
$3,220.75
20%
$644.15
March 3, 2020- March 31, 2020
Dialysis
$1,739.50
20%
$347.90
April 2, 2020-
April 30, 2020
Dialysis
$3,025.36
20%
$605.02
May 2, 2020-
May 30, 2020
Dialysis
$4,021.16
20%
$804.18
June 2, 2020-
June 30, 2020
Dialysis
$3,673.60
20%
$734.72
TOTAL:
$3,780.77
Dialysis falls within the "Services to treat kidney disease" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for dialysis provided from January 2, 2020, through June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the complete upper denture (D5110) and the partial lower denture (D5212) provided on November 3, 2020.
You asked the Plan to waive the copayment for the dental items. You say that you were not advised that there was a $150 copayment for dentures. You say that you were advised by a plan representative that dentures would be covered in full. You also say that you do not want to pay the $150 copayment for the dentures. The Plan denied your request. The Plan says there is a $150 copayment for complete or partial dentures, once per arch, per 60 months.
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 and dentures are a covered service, there is a $150 copayment for complete or partial dentures, per arch. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the copayment for the complete upper denture (D5110) and the partial lower denture (D5212) provided on November 3, 2020.
Your complaint about being misinformed by a plan representative 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95816) provided September 1, 2020.
You asked the Plan to pay for the electroencephalogram. You say that the service was medically necessary. The Plan denied your request. The Plan says this code shares a bundled relationship with another code billed and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95816 has a Column I / Column II relationship with code 95720 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95816) provided September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoscopic discectomy at spinal level L5-S1.
You asked the Plan to pre-approve the requested endoscopic discectomy. You say that it is felt that this type of procedure is likely to improve the enrollee's condition. The Plan denied your request. The Plan says the documentation provided does not support the need for the proposed surgery.
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 requested endoscopic discectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 66-year-old woman with a diagnosis of Spinal stenosis, lumbar region with neurogenic claudication. The enrollee has a disc herniation and moderate stenosis. The enrollee has pain in her right leg in the L5 distribution that radiated down the lateral thigh and in the lateral leg. The enrollee also has numbness in the L5 distribution. The Achilles reflex is absent on the right side. An MRI on 6/19/20 revealed mild lumbar spondylosis without evidence of a large focal disc herniation, high-grade central canal stenosis, or cord compression. At L5-S1 there was mild annular disc bulging and bilateral hypertrophic facet disease without significant central canal stenosis. The clinical documentation and the MRI result does not support that discectomy at L5-S1 level is medically reasonable and necessary for the enrollee in this case. 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 requested endoscopic discectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoscopic discectomy at spinal level L5-S1.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on August 11, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 97112-GP, J3415, and J3490 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J3490 is unclassified drugs. We find that CPT codes 97112, J3415, and J3490 are not supported in the medical record. Specifically, there is no documentation of time spent as a separate and distinct procedure and detailed description of the specific neuromuscular reeducation performed to support code 97112. The documentation shows that nutri-pharmaceutical blend was administered and the services were already processed on the date of service; therefore, codes J3415 and J3490 are not supported. 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 services rendered on August 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The documentation does not support that the enrollee's functional level requires skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on February 24, 2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you should not be paying for a mammogram. The Plan denied your request. The Plan says the copayment 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $110 copayment for the breast ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The ultrasound is considered diagnostic radiology, which applies a copayment. 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 breast ultrasound provided on February 24, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 1, 2020.
You asked the Plan to pay for the physician service. You say that the service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 office visit provided on April 1, 2020.