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

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 2, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.
Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a general health panel (CPT 80050) provided to the enrollee on January 26, 2021.
You asked the Plan to pay for the services. You say that you didn't request to have this lab service. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by Medicare. However, a GHP consists of three separate lab services which may be billed and paid for separately: 1. a comprehensive metabolic panel ("CMP"; code 80053); 2. a complete blood count ("CBC"; code 85025);
3. a thyroid stimulating hormone ("TSH"; code 84443). The rules say that CMPs are covered when they are reasonable and necessary. The rules say that CBCs and TSHs are covered only for certain medical indications. You have requested payment for a GHP, billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, the Plan does not have to pay for the GHP billed under code 80050. Because payment cannot be made for the GHP, we looked to see if rules had been met for the three services that comprise a GHP.
With respect to the CMP, 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 services Our reviewer says that Our physician reviewer found 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 CMP have not been met. Therefore, the Plan does not have to pay for the CMP. With respect to the CBC, we found that you do not have a medical condition for which this service may be covered. Therefore, the Plan does not have to pay for the CBC. With respect to the TSH, we found that you do not have a medical condition for which this service may be covered. Therefore, the Plan does not have to pay for the TSH. Therefore, we decided that the Plan does not have to pay for a general health panel (CPT 80050) provided to the enrollee on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 28, 2019, to May 6, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you received a letter indicating you did not owe any money for the services rendered. You also say that you were unaware of any charges prior to leaving the hospital and received a claim in 2020. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $275 copayment per day, for days 1-5 of inpatient hospital care. The Plan contract also says that you pay $0 for days 6 and beyond of inpatient hospital care. You have been asked to pay a $275 copayment per day for inpatient hospital care ($275 x 5 days = $1,375). The EOC confirms that $275 per day is the required copayment for this service. The records show that you received a letter on May 3, 2019, stating that the inpatient services rendered at the hospital were not approved. The claim was reprocessed on October 13, 2020, and the cost share was applied according to your benefits outlined in your 2019 EOC. 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 inpatient hospital care provided on April 28, 2019, to May 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and pay for the injection provided on February 4, 2021.
You asked the Plan to waive the deductible for the office visit (99214) or pay for the Injection, ceftriaxone sodium, per 250 mg (J0696). You say that the injection was part of your treatment. The Plan denied your request. The Plan says the office visit has been charged to your deductible and the injection claim was not submitted by the provider correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $150 deductible for covered medical services. The office visit allowed amount of $136.98 falls under deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible for medical services. This cost sharing is a contractual obligation that had not been met at the time the office visit. The injection, ceftriaxone sodium, per 250 mg (J0696) has a different National Drug Code number and therefore cannot be paid until a corrected claim is submitted from the provider. Therefore, we decided that the Plan does not have to waive the deductible for the office visit or pay for the injection provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 28, 2021.
You asked the Plan to pay for the resin-based composite. You say that you would like this service to be reconsidered for coverage. The Plan denied your request. The Plan says this service is not covered under your benefit 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 resin-based composite provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. 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 office visit provided on February 21, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on January 6, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says exploratory exams such as limited oral evaluation or problem are not a covered benefit under your plan. The Plan also says that neither you nor your provider contacted the Plan prior to this date of service to confirm your dental coverage.
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 problem focused limited oral evaluation provided on January 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 9, 2021.

You asked the Plan to pay for the subsequent nursing facility care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that modifier "-58" was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure.

We looked at the file and Medicare rules. The file shows that the services were rendered within the 0 day global surgical period for procedure 11042 (subcutaneous tissue debridement) and were not billed with the required -58 modifier. Based on this information, we decided that Medicare rules for coverage of the subsequent nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on December 21, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.

We looked at the file and Medicare and the Plan's rules.

Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01936) provided on November 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for anesthesia. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 anesthesia (01936) provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 25, 2021.
You asked the Plan to pay for a telehealth visit. You say that this was billed correctly. 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 providers should submit telehealth services claims, using Place of Service (POS) 02-Telehealth, to indicate they furnished the billed service as a professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasounds provided on July 31, 2020.
You asked the Plan to waive the copayment for the ultrasounds. You say that this was your annual, but this was
billed as diagnostic. You say that you will pay the bill when you know it is right. The Plan denied your request.
The Plan says the copayments 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 $125
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility.
You have been asked to pay a total of $156.36 for the ultrasounds.
Service Allowed Amount Standard Copayment Member Liability
Left Breast Ultrasound $52.12 $125 $52.12
Right Breast Ultrasound $104.24 $125 $104.24
TOTAL: $156.36
The ultrasounds fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit
category. The ultrasounds are considered a diagnostic service. 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 ultrasounds provided on July 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a bone imaging and a computed tomography (CT) scan of the abdomen and pelvis (78306,74177) provided on November 2, 2020.

You asked the Plan to waive the co-payment for a bone imaging and a CT scan of the abdomen and pelvis. You say that you disagree with the charges. The Plan denied your request. The Plan says the co-payment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co-payment per day, for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $250 co-payment for a bone imaging and a CT scan of the abdomen and pelvis.
The EOC confirms that $250 is the required co-payment per day for these services. Bone imaging and a CT scan
of the abdomen and pelvis 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 co-payment for a bone imaging and a computed
tomography (CT) scan of the abdomen and pelvis (78306,74177) provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 1, 2020.
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 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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient 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 G0482 provided on July 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on April 26, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on April 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110) provided on January 5, 2021.
You asked the Plan to pay for a complete upper denture. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 a complete upper denture (D5110) provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 receiver, for the enrollee.

You asked the Plan to pre-approve the receiver. You say that the receiver is medically necessary. The Plan denied your request. The Plan says the enrollee has functioning equipment currently and the enrollee does not meet for replacement per the Health Plan guidelines.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The quantity limit for this is 1 receiver every 720 days. The Plan may be able to make an exception to this limit and approve the requested amount. The enrollee's prescriber will need to send the Plan a statement explaining why the enrollee needs this quantity. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 receiver, for the enrollee.