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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 18, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the endovenous ablation therapy (36478) provided on September 4, 2019.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.

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 this service was not filed until January 18, 2021. 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 pay for the endovenous ablation therapy (36478) provided on September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a total knee arthroplasty (27447) provided on January 11, 2021.

You asked the Plan to pay for a total knee arthroplasty. You say that this should be covered. The Plan denied your request. The Plan says this exceeds MUE.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 27447 is 1. You billed 2 units of this code, the first of which was billed and paid on a separate claim, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a total knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for a total knee arthroplasty (27447) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on November 18, 2020.

You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan's network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 ophthalmological services provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on January 14, 2021.

You asked the Plan to pay for the dental service. You say that after talking to a plan representative, you now understand that this x-ray is only covered once every 3 years. You say that you were not aware of this prior to your appointment. You also say that you do not know where you would have found this information. The Plan denied your request. The Plan says 1 complete series x-ray or panoramic x-ray every 5 years. The Plan also says that the frequency limit has been exceeded.

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 complete series x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray performed on March 18, 2019. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on November 9, 2020.

You asked the Plan to pay for train of four testing. You say that this is a covered service. The Plan denied your request. The Plan says this 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. 

We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on September 23, 2020.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 the genetic testing is not supported in the medical record. Specifically, these services should be billed with code 81479. In addition, the approved DEX-Z code should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown (D6740) and to pay more for the pontic (D6245) provided on February 5, 2021.

You asked the Plan to pay for the retainer crown or pay more for the pontic. You say that your policy has a maximum benefit of $2,500. The Plan denied your request. The Plan says your annual maximum benefit of $2,000 has been met.

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 Plan offers a $2,000 annual dental benefit maximum. The record shows that you met the annual maximum benefit while processing this claim for the February 5, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6740) and to pay more for the pontic (D6245) provided on February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 11, 2021.

You asked the Plan to pay for the ambulance services. You say that you did not request this service. 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 January 11, 2021. 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 provided on January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the fasciectomy services coded 26123 and the excision or curettage of bone cyst or benign tumor of radius or ulna coded 25125 provided on November 13, 2020.

You asked the Plan to pay for the fasciectomy services and the excision or curettage of bone cyst or benign tumor of radius or ulna. 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 26123 and 25125 are not supported in the medical record. Specifically, the operative report did not include documentation of partial palmar fasciectomy with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); therefore, code 26123 cannot be verified. The operative report did not include documentation of an excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with autograft (includes obtaining graft); therefore, code 25125 cannot be verified. 

Based on this information, we decided that Medicare rules for coverage of the fasciectomy services and the excision or curettage of bone cyst or benign tumor of radius or ulna have not been met. Therefore, we decided that the Plan does not have to pay for the fasciectomy services coded 26123 and the excision or curettage of bone cyst or benign tumor of radius or ulna coded 25125 provided on November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on September 30, 2020.

You asked the Plan to pay for the neuromuscular stimulator (E0745). 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.

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 a valid proof of delivery for the supplies provided in this case. There is no proof of delivery documentation in the file. 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 neuromuscular stimulator provided on September 30, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the outpatient hospital services provided on June 22, 2020.

You asked the Plan to pay for the outpatient hospital services. You say that the medical records support the services rendered. The Plan denied your request. The Plan says that The facility must furnish all necessary covered services/supplies to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services during or in preparation for a procedure or surgery at the facility. Payment for this service would be included in the facility PPS payment. Payment for this service is the responsibility of the facility.

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. The Plan has provided no valid denial rationale to justify denial of payment for these services. The Plan has stated that payment cannot be made for these services because payment is only made to the facility through the prospective payment system (PPS) for services furnished to the beneficiary in preparation for, during, or following a procedure or surgery. However, this claim is the facility requesting PPS payment for the services rendered to the enrollee on the date of this surgery. There is no evidence payment was made to any other provider for these services. We find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the outpatient hospital services provided on June 22, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation (D9223, D9222) received January 19, 2021.

You asked the Plan to pay for the deep sedation. You say that the requested services should be covered. The Plan denied your request. The Plan says general anesthesia and intravenous sedation will only be paid in conjunction with qualified services.

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 deep sedation when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. The Plan does not cover deep sedation in conjunction with the services you received. Based on this information, we decided that the Plan's rules for coverage of the deep sedation have not been met. Therefore, we decided that the Plan does not have to pay for the deep sedation (D9223, D9222) received January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic CGM (K0554) and CGM supplies (K0553) provided on January 7, 2021.

You asked the Plan to pay for a therapeutic CGM and CGM supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

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 a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery notes a need for a signature upon delivery. The document is not signed. 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 a therapeutic CGM (K0554) and CGM supplies (K0553) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test provided on December 14, 2020.

You asked the Plan to waive the copayment for a hearing test. You say that you disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $10 copayment for diagnostic procedures and tests. 

You have been asked to pay a $10 copayment for a hearing test. A hearing test 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 a hearing test provided on December 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on October 18, 2020.

You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 the Guardant360 testing is not supported in the medical record. Specifically, these services were billed as multiple CPT codes. These services should be billed as a single panel code (81479). Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on October 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on January 13, 2021.

You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges because you already met the deductible prior to receiving the services and should only owe a $15 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $290 deductible for physician/practitioner services, including doctor's office visits. 

You had an office visit on January 13, 2021. The record shows that you had only paid $273.83 toward the $290 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $16.17. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on January 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on December 8, 2020, by an out-of-network provider.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, and the services were 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 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 laboratory services provided to the enrollee on December 8, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed tomography (CT), abdomen
and pelvis (74178) and an ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image
documentation (76770) provided on December 1, 2020 and December 23, 2020.

You asked the Plan to waive the copayment for a CT of the abdomen and pelvis and a retroperitoneal
ultrasound. You say that the cost share is incorrect. The Plan denied your request. The Plan says the cost share
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 $95 basic radiological services copayment at an outpatient hospital for Outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $95 basic radiological services copayment at an outpatient hospital for a retroperitoneal ultrasound. You have been asked to pay a $275 advanced imaging services copayment at an outpatient hospital for a CT of the abdomen and pelvis. These services fall 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 a Computed tomography (CT), abdomen and pelvis (74178) and an ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation (76770) provided on December 1, 2020 and December 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided on January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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 ultrasound provided on January 11, 2021 by an out of network (OON) provider.