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

We decided that the Plan does not have to pay for the office visit and imaging services provided on August 21, 2020 by a non-participating provider.
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 the services were rendered by a non-participating provider without prior authorization.
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 and imaging services provided on August 21, 2020 by a non-participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay from April 3, 2020, to May 31, 2020.

You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $178 copayment for days 21-100 for SNF care. 

The enrollee has been asked to pay $1,831.31, which is less than the total copayment amount for a SNF stay. A SNF stay falls within the SNF care 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 copayment for a SNF stay from April 3, 2020, to May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 11, 2020 and September 2, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 11, 2020 and September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the gauze coded A6219 provided on December 17, 2020.

You asked the Plan to pay for the gauze. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 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, the CPT Code Manual definition of code A6219 is gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing. 

We find that CPT code A6219 is not supported in the medical record. Specifically, these items are related to the debridement procedure that was performed on the same date of service. This code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the gauze have not been met. Therefore, we decided that the Plan does not have to pay for the gauze coded A6219 provided on December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 3, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.
We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 3,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 12, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular genetic testing (81286, 81407, 81408, 81479) provided on October 1, 2020.
You asked the Plan to pay for cardiovascular genetic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiovascular genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic testing (81286, 81407, 81408, 81479) provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning provided on October 7, 2020.
You asked the Plan to pay for the fixed partial denture sectioning. You say that you would like this service to be covered. The Plan denied your request. The Plan says there are no benefits available for this dental service.
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 fixed partial denture sectioning provided on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) provided on August 6, 2019.

You asked the Plan to pay for determination of refractive state. You say that the provider was recommended by the Plan and the provider is also listed as a participating provider in Plan documentation. The Plan denied your request. The Plan says the service at issue 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. This service is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015) provided on August 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on June 30, 2020.

You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not 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.

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 not supported in the medical record. Specifically, the submitted medical records show that fewer than 22 drug classes were tested. 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 June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), scaling in the presence of moderate or severe gingival inflammation (D4346), gingival irrigation (D4921) for multiple quadrants, oral hygiene instructions (D1330) and an unspecified periodontal procedure (D4999) provided on November 10, 2020.
You asked the Plan to pay for the dental services. You say that you have not received any other dental services this year and do not understand why these services are not covered. You have money left in your benefit. You say that the provider informed you that the services provided were covered by the Plan. The Plan denied your request. The Plan says they previously paid for a comprehensive oral evaluation in 2019. This service can only be covered once every three years. Therefore, this service exceeds the Plan's benefit allowance. The other services provided are not covered by Medicare or by the Plan's supplemental dental benefit under any circumstances.
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 or were provided in a frequency that exceeds that which is allowed by the Plan. The Plan provided documentation that they paid for a comprehensive oral evaluation in 2019, which is less than three years prior to the date in question. The other services in question are not listed as covered services in your 2020 contract. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), scaling in the presence of moderate or severe gingival inflammation (D4346), gingival irrigation (D4921) for multiple quadrants, oral hygiene instructions (D1330) and an unspecified periodontal procedure (D4999) provided on November 10, 2020.
Your complaint about potential misinformation regarding covered services from a Plan-contracted provider 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair services coded 26356 provided on June 17, 2020.

You asked the Plan to pay for the repair 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 supported by the documentation.

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 26356 is repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon. 

We find that CPT code 26356 is not supported in the medical record. Specifically, the operative report did not include documentation of a primary repair or advancement of a flexor tendon, in zone 2 digital flexor tendon sheath (no man's land), without free graft, of each tendon; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the repair services have not been met. Therefore, we decided that the Plan does not have to pay for the repair services coded 26356 provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of the torus mandibularis (D7473 x 2), an initial 15 minutes of deep sedation (D9222), and an additional 15 minutes of deep sedation (D9223 x 3).
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says removal of the torus mandibularis is not listed as a covered service. The Plan also says that deep sedation is covered only for extractions, and for other services covered with medical justification.
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 removal of the torus mandbiularis is not among those covered under this benefit. Although deep sedation is listed as a covered service, it is excluded from coverage when the primary service is not covered. Therefore, we decided that the Plan does not have to pre-approve removal of the torus mandibularis (D7473 x 2), an initial 15 minutes of deep sedation (D9222), and an additional 15 minutes of deep sedation (D9223 x 3).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse, per 15 minutes (G0299 x 2), and direct skilled nursing services of a licensed practical nurse (LPN) (G0300 x 11).
You asked the Plan to pre-approve 4 additional skilled nursing visits. You say that the enrollee is not able to turn himself so that wound care to be provided. You also say that these services are medically necessary. The Plan denied your request. The Plan says there was no wound information provided. The Plan also says that the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 1 additional skilled nursing service, and
3 additional skilled nursing services provided by an LPN. Our reviewer says that the additional services are not medically necessary. Our physician reviewer found the provided documentation does not show that additional services are currently required. The reviewer found that the enrollee is receiving appropriate care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 additional skilled nursing service, and 3 additional skilled nursing services provided by an LPN have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse, per 15 minutes (G0299 x 2), and direct skilled nursing services of a licensed practical nurse (LPN) (G0300 x 11).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on December 23, 2020.
You asked the Plan to waive the copayment for these services. You say that you did not have any services on this date. The Plan denied your request. The Plan says the copayment 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 $45 copayment per visit for specialist services.
Review of the file shows that you received specialist services on December 23, 2020. The records show that you had a telemedicine visit with a urologist on this date. You have been asked to pay a $45 copayment for these services. These services fall within the specialist services 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 specialist services rendered on December 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73560) provided July 30, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $15 copayment for outpatient x-rays. You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the outpatient x-rays 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 (73560) provided July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and vaccine provided by an out-of-network provider on November 5, 2019.

You asked the Plan to pay for the office visit and vaccine. You say that a retro authorization can be submitted with records and appeal. The Plan denied your request. The Plan says in-network providers were available, and authorization was not obtained prior to 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 office visit and vaccine provided by an out-of-network provider on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical lymphadenectomy (38724-22) and an ultrasound (76536) provided on October 30, 2020.
You asked the Plan to pay for a cervical lymphadenectomy and an ultrasound. You say that these codes are documented. The Plan denied your request. The Plan says these codes 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 38724 is cervical lymphadenectomy (modified radical neck dissection). Modifier 22 is used to indicate increased services. The definition of 76536 is ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation. 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 cervical lymphadenectomy and an ultrasound. Our reviewer says that the billing of these codes is not supported by the records. Our physician reviewer found the operative report does not include enough documentation to support increased services for lymph node removal to confirm modifier 22 on code 38724. Code 76536 is not supported because the documentation shows that ultrasound was performed for guidance, which is not appropriate for the billed code. 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 cervical lymphadenectomy and an ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for a cervical lymphadenectomy (38724-22) and an ultrasound (76536) provided on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on November 17, 2020.