Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid (HCPCS V5257) provided to the enrollee on August 5, 2020.

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 submitted documentation contained a physician's order, however it does not include a detailed description of the item.

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 HCPCS code V5257 is "Hearing aid, digital, monaural, bte." 

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 supported by the medical records. Our coding reviewer found the documentation did not include a valid physician's order to include the items. Suppliers must maintain a valid physician order, prior to delivery, to confirm services were ordered by a physician.

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 a hearing aid (HCPCS V5257) provided to the enrollee on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99204) provided to the enrollee on November 30, 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 there is no evidence that the provider contacted the plan to verify insurance, current eligibility, or authorization requirements. The Plan states the provider failed to request prior authorization before rendering services and there is also no evidence of plan directed care.
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 99204) provided to the enrollee on November 30, 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 occlusal adjustments (D9952) provided on November 24, 2020.

You asked the Plan to pay for the occlusal adjustments. You say that you would like these services to be covered. The Plan denied your request. The Plan says this procedure is not covered under your dental plan. The Plan also says that prior to this date of service you were advised by the provider and the Plan that this service was not covered by your plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal adjustments (D9952) provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings provided on November 19, 2020.
You asked the Plan to pay for the scalings and planings. You say that you were misinformed that these services would be covered. The Plan denied your request. The Plan says this service is not covered. The Plan says that the provider contacted the Plan on November 19, 2020 and general benefits were provided but there was no mention of periodontal scaling.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings provided on November 19, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a laparoscopic prostatectomy (55866-22) provided on August 10, 2020.
You asked the Plan to pay for a laparoscopic prostatectomy. You say that this is supported. The Plan denied your request. The Plan says that this is not documented.
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 55866 is laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed. 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 a laparoscopic prostatectomy. Our reviewers says that this code and modifier 22 for increased services are supported in the records. Our physician reviewer found the operative report documents a retropubic radical prostatectomy with nerve sparing, using robotic assistance. An incision was made retropubicly, with increased procedural services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a laparoscopic prostatectomy have been met. Therefore, we decided that the Plan has to pay for a laparoscopic prostatectomy (55866-22) provided on August 10, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower provided November 20, 2020.

You asked the Plan to pre-approve a walk-in shower. You say that this was medically necessary after your spinal surgery. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower provided November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the hearing aids purchased on January 14, 2019.
You asked the Plan to provide reimbursement for the hearing aids. You say that you feel that you should be allowed reimbursement for this because you relied on the information given by the Plan to go to this provider. You requested an appeal in 2019 but then were told the Plan did not receive it. You then submitted a second reimbursement request which was denied. You believe that you are due repayment since you believed this would be covered. The Plan denied your request. The Plan says you did not submit the current claim for reimbursement until more than one year after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the hearing aids was not filed until July 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to provide reimbursement for the hearing aids purchased on January 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on July 10, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The service at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 25, 2020, to August 31, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that your copayment should just be $75. 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 $195 copayment per day for days 1-7. there is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $195 copayment per day for days 1-6 for an inpatient hospital stay. The total amount you are being asked to pay is $1,170 ($195 x 6 days = $1,170). An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided by a participating provider on August 25, 2020, to August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic diagnostic imaging (92134) and eye exam (92014) provided on October 9, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the ophthalmic diagnostic imaging and eye exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or 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 ophthalmic diagnostic imaging (92134) and eye exam (92014) provided on October 9, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses (L1852) provided December 16, 2020.
You asked the Plan to pay for the knee orthoses. You say that these items were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a physician order for the billed date of service.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records do not include a complete history of the patient's medical condition illustrating the need for the requested orthoses. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthoses (L1852) provided December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation treatment provided by a chiropractor from October 27, 2020, to November 3, 2020.
You asked the Plan to pay for electrical stimulation. You say that you believe you were misled by the provider's office about your coverage, as they were misinformed by the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this service is not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that they have overturned and approved payment for the manual manipulation services, so this denial is only for electrical stimulation services.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation treatment provided by a chiropractor from October 27, 2020, to November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Invitae hereditary cancer test.

You asked the Plan to pay for the testing services. You say that the test clarifies disease risk. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit for the diagnosis listed on the claim.

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 testing services were 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 the Invitae hereditary cancer test.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and the periodontal maintenance (D4910) provided on December 2, 2020.

You asked the Plan to pay for the dental services. You say that you paid for the services in full at the time you received the services. You say that you had an infection which was life threatening due to your heart condition. You also say that you had no choice but to have this procedure done. The Plan denied your request. The Plan says topical application of fluoride varnish is not listed as a covered service. The Plan says that periodontal maintenance is not listed as a covered service either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) and the periodontal maintenance (D4910) provided on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block provided on December 4, 2020.

You asked the Plan to pay for the genicular nerve block. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.

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 pay for the genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has bilateral osteoarthritis of the knees. The enrollee has tried physical therapy and it made the pain worse. The enrollee has tried rest which helps and anti-inflammatory medications. The services rendered are considered an experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore, the enrollee did not meet criteria for the services rendered.

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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for multiple unspecified dental services (D9999) provided on August 28, 2020.

You asked the Plan to pay for the dental services. You say that you were told you did not need to use an in-network provider for dental services, and do not understand why your request for reimbursement is denied. The Plan denied your request. The Plan says you can use an in-network or out-of-network provider for dental care, but the provider must participate in (accept) Medicare insurance. The provider in question chose not to participate in Original Medicare, and therefore no payment can be provided.

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 items or services can only be covered when they are received from a provider who participates in Medicare. Therefore, we decided that the Plan does not have to pay for multiple unspecified dental services (D9999) provided on August 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (CPT code 90846) provided on November 3, 2020, Licensed Professional Counselor (LPC).

You asked the Plan to pay for the services. You say that you were referred by your Primary Care Provider (PCP) and were unaware that you were going to an out-of-network provider. The Plan denied your request. The Plan says they contacted your PCP and were told by your PCP there is no record of a referral to this provider.

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.

This type of provider is not eligible to enroll in the Medicare program. Furthermore, the Plan stated they contacted your PCP who told the Plan that the services were not referred. Therefore, we decided that the Plan does not have to pay for psychotherapy (CPT code 90846) provided on November 3, 2020, Licensed Professional Counselor (LPC).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on July 24, 2020.

You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says that the documentation does not show that 22 or more drug classes were tested.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily Stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is supported in the medical record. Specifically, the submitted medical records include documentation of 22 drug classes being tested. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on July 24, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the application of a skin substitute provided on October 14, 2020 billed with code 15271.
You asked the Plan to pay for the skin substitute application. You say that this service was clearly performed per the note where it was noted that the Affinity wound dressing was applied. The Plan denied your request. The Plan says that the records did not include documentation to support this code.
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 15271 is Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. We find that CPT code 15271 is supported in the medical record. Specifically, the progress note clearly documents that the wound was treated and documents that the Affinity skin substitute was placed as a wound dressing of 6.25 sq. cm. Based on this information, we decided that Medicare rules for coverage of the skin substitute application have been met. Therefore, we decided that the Plan has to pay for the application of a skin substitute provided on October 14, 2020 billed with code 15271.