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

We decided that the Plan does not have to pay for the topical application of fluoride varnish (code D1206) provided on October 17, 2019.You asked the Plan to pay for the topical application of fluoride varnish. You say that you were under the impression that the services you received were covered.The Plan denied your request. The Plan says this service is not covered by your dental 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 topical application of fluoride varnish (code D1206) provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on March 28, 2019.You asked the Plan to pay for the drug testing. 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.We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on March 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on July 5, 2019.
You asked the Plan to pay for the hospital discharge day management 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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted did not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed date of service of July 5, 2019. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on July 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 3, 2018 through August 14, 2018.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There is no evidence provided to suggest that rules for Medicare coverage of these services have not been met. Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 3, 2018 through August 14, 2018.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64495 provided on August 13, 2019.
You asked the Plan to pay for the injection 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 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). We find that CPT code 64495 is not supported in the medical record. Specifically, the documentation does not support that injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third level was performed. . Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64495 provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Planhasto pay forthe blood glucose test strips provided from July 1, 2019 to October 1, 2019 billed with code A4253-KS.You asked the Planto pay forthe test strips as billed. You say that this was billed with the correct modifier based on the Medicare instructions.The Plandenied your request. The Plansaysthatthis code must always be billed with the modifier -NU.The Plan must follow Medicare rules. Medicare rules say that test strips must reportmodifier -KS when provided to enrollees who are not insulin-treated. In this case, MAXIMUS found no clear indications that this code is not payable without the -NU modifier. Some documents were reviewed from the DME MAC CGS Medicare which indicates the requirement of the modifier. However, the controlling MAC for this state is Noridian which has no such regulations posted. The fee schedule does include the modifier -NU associated with the code; however, there is no other possible modifier which could be reported which would change the reimbursement amount. For example, modifier -UE could not be reported as test strips cannot be provided if used, and could only be provided new. As such, we find that the exclusion of the -NU modifier does not rise to the level of a reporting error which would warrant non-payment for the supplies at issue. The DME MAC Policy Article modifier is correctly reported and the modifier -NU would add no additional necessary information that would be required to make payment.Therefore, we decided that the Planhas to pay forthe blood glucose test strips provided from July 1, 2019 to October 1, 2019 billed with code A4253-KS.If the Plandoes 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/orsend 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab work provided on July 23, 2019 by the out of network provider. You asked the Plan to pay foroutpatient lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtainedfor these services.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 areaurgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 foroutpatient lab work provided on July 23, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
August 6, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on August 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee must have had previous treatment, contraindication, or intolerance with Orthovisc and Monovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary. Our physician reviewer found the enrollee has no tried and failed Monovisc and Orthovisc. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-segmental and segmental pneumatic appliances
provided on August 21, 2019.
You asked the Plan to pay for the non-segmental (E0655) and segmental pneumatic appliances. You say that
the Plan should pay this claim. The Plan denied your request. The Plan says the documentation did not include
an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery 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 shows the pickup date is September 12, 2019 and the claim date of service is August 21, 2019.
Therefore, we decided that the Plan does not have to pay for the non-segmental and segmental pneumatic
appliances provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by an out-of-network 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 has network providers available who can provide 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 medical services provided on July 24, 2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection services coded 87633 provided
on October 30, 2019.
You asked the Plan to pay for the infectious agent detection 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 a covered
benefit.
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 87633 is Infectious agent detection by nucleic acid (DNA
or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets.
We find that CPT code 87633 is not supported in the medical record. Specifically, this code has a status code of
X. A status code of X means that this code represents a service that is not in the statutory definition of
"physician services" for fee schedule payment purposes. No payment can be made for this service. Based on
this information, we decided that Medicare rules for coverage of the infectious agent detection services have
not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection
services coded 87633 provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on June 3, 2019.
You asked the Plan to pay for screening tests. You say that you are appealing with records to support the services billed. The Plan denied your request. The Plan says the denial of payment for these services is correct, because a treating provider did not order these tests, the enrollee did not have any signs or symptoms to indicate these tests were medically necessary, and the testing is not being used to manage or treat a specific medical problem or diagnosis.
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, screening tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on June 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, resin-based composite - one surface, and resin-based composite - two surfaces provided on August 30, 2018 and September 20, 2018.
You asked the Plan to pay for the oral evaluation and resin-based composites. You say that the Plan confirmed that you are only participating with the Plan for medical services and not dental services. You also say that the provider failed to verify your insurance information prior to rendering the services. The Plan denied your request. The Plan says these services were provided by an out-of-network provider without a prior authorization.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, resin-based composite - one surface, and resin-based composite - two surfaces provided on August 30, 2018 and September 20, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were treated by Emergency Medical Technicians who were called out to your home. You say that you were not transported. You also say that you received an explanation of benefits saying that you were not responsible for the claim. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of bupivacaine hydrochloride provided on July 31, 2018.
You asked the Plan to pay for injection. You say that you are appealing with medical records. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because procedure code S0020 is
not valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that procedure code S0020 is not valid for Medicare
purposes and is not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of injection have not been met. Therefore, we decided that the Plan does not have to pay for an
injection of bupivacaine hydrochloride provided on July 31, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health services provided to the enrollee on June 15, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan contract indicates outpatient mental health care requires prior authorization. You are not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 mental health services provided to the enrollee on June 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an
out-of-network 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-network 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 has network providers
available who can provide 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 medical services provided on September 27,
2019 by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the removal of impacted ear wax, and the cleaning
out of the mastoid cavity provided on August 27, 2019.
You asked the Plan to reimburse you for the surgical services. 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.
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 reimburse you for the removal of impacted ear wax, and the cleaning
out of the mastoid cavity provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on to the enrollee on September 24, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 has network providers available who can provide 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 medical services provided on to the enrollee on September 24, 2019.