Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forpodiatry services (29580) provided June 4, 2020.You asked the Plan to pay forthe podiatry services. You say that the services were medically necessary.The Plan denied your request. The Plan says a required modifier was missing from the claim.The Plan must follow Medicare rules. Medicare rulessay that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 29580 is not supported in the medical record. Specifically, a required anatomical modifier was not included. Without this modifier it is unclear which leg/foot the boot was applied to. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met.Therefore, we decided that the Plan does not have to pay forpodiatry services (29580) provided June 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 7, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you are not back to normal after three surgeries. The Plan denied your request. The Plan says the copayment 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 $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on June 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost stabilization care provided from 4:02 pm on May 3, 2020, through May 4, 2020.You asked the Plan to pay forpost stabilization care. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says they are not legally obligated to pay the hospital (and provider) for the unauthorized post-stabilization care at issue because the enrollee's emergency medical condition had stabilized by 4:01 p.m. on May 3, 2020 and the hospital did not promptly notify the Plan upon stabilization of the enrollee's emergency medical condition or request authorization from the Plan prior to providing post-stabilization services.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post stabilization care. Our reviewer says that post-stabilization care services at the non-Plan facility after 4:01 p.m. on May 3, 2020 were not medically necessary or reasonable. Our physician reviewer found the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. The review indicates that by 4:01 p.m. on May 3, 2020, the enrollee was stable for ambulance transport with monitoring to a Plan facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of post stabilization care have not been met. Specifically, you did not receive prior authorization from the plan.Therefore, we decided that the Plan does not have to pay forpost stabilization care provided on May 3, 2020, through May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral
periapical x-ray, two additional intraoral periapical x-rays, preventive procedure, core buildup, including any
pins when required, endodontic therapy, and three resin-based composites provided from June 23, 2020, to July
9, 2020.
You asked the Plan to pay for the dental services. You say that you believed that your dental work would be
covered at 50%, due to having seen an out-of-network provider. The Plan denied your request. The Plan says
the problem focused limited oral evaluation, first intraoral periapical x-ray, two additional intraoral periapical
x-rays, preventive procedure, core buildup, including any pins when required, and endodontic therapy are not
covered benefits. The Plan also says that your benefits for the resin-based composites have been satisfied and
the frequency limitation 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, the problem focused limited oral
evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, preventive procedure, core
buildup, including any pins when required, and endodontic therapy are not among those covered under this
benefit. The contract clearly says that composite restorations are limited to one procedure per calendar year.
The record shows that you received four resin-based composites on June 25, 2020, one of which was covered
by the Plan, and your composite restorations benefit has been exhausted. Therefore, we decided that the Plan
does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, two
additional intraoral periapical x-rays, preventive procedure, core buildup, including any pins when required,
endodontic therapy, and three resin-based composites provided from June 23, 2020, to July 9, 2020.
Your complaint about possibly being misled by the Plan representative you spoke with 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 forthe surgical services rendered on March 6, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 27513-58-RT and 27513-58-59-LT are not covered.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 27513 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services rendered on March 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe spinal procedures provided on June 23, 2020.You asked the Plan to pay forarthrodesis (22612, 22614), decompression spine (63056,63057), and Posterior segmental instrumentation (22842). You say that the procedures were medically necessary.The Plan denied your request. The Plan says the codes are not supported in the medical record.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 codes22612, 22614, 63057, 63056, 22842 arenot supported in the medical record. Specifically, the procedure codes are not substantiated by the clinical documentation. Based on this information, we decided that Medicare rules for coverage of arthrodesis (22612, 22614), decompression spine (63056,63057), and Posterior segmental instrumentation (22842) have not been met.Therefore, we decided that the Plan does not have to pay forthe spinal procedures provided on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing (81328, 81408, 81406, 81405, 81479) provided May 5, 2020.You asked the Plan to pay forthe genetic testing. You say that these services were medically necessary.The Plan denied your request. The Plan says the ordered tests are not covered as a screening service.The Plan follows Medicare rules. The rules explicitly say that screeningtests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forgenetic testing (81328, 81408, 81406, 81405, 81479) provided May 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe wound care supplies rendered on May 26, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered in a SNF.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that these services was used in a SNF or hospital.Therefore, we decided that the Plan does not have to pay forthe wound care supplies rendered on May 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual wellness exam you had on July 14, 2020.You asked the Plan to pay forthe exam. The Plan denied your request. The Plan says this is only covered once per year.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 $0 copayment for oneannual wellness visit per calendar year. Review of the file show that you had an annual wellness exam on July 14, 2020. The Plan covers one wellness exam per calendar year. The records show that you had a covered wellness exam on January 16, 2020. The requested exam exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to pay forthe annual wellness exam you had on July 14, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 13, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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
laboratory services. 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 laboratory services provided on August 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe duplex scan (93970) provided on May 8, 2020.You asked the Plan to pay forthe duplex scan. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted record supports one unit of CPT code 93970 which was approved.The Plan must follow Medicarerules. 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 93970 is duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study.We find that CPT code 93970 is not supported in the record. Specifically, the record supports one unit of CPT code 93970. One unit of CPT code 93970 has been approved by the Plan. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met.Therefore, we decided that the Plan does not have to pay forthe duplex scan (93970) provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic care provided from June 29, 2020, to August 3, 2020.You asked the Plan to pay forthis service. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says those services billed by your provider that are not manual manipulation of the spine are not covered by the Plan orby Medicare.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forchiropractic care provided from June 29, 2020, to August 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 6, 2020. You asked the Plan to pay for the ambulance services. 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 April 6, 2020. 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 April 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on March 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this reprocessed and paid.The Plan denied your request. The Plan says prior authorization had expired. The Plan says prior authorization was not obtained for this visit.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 forphysician services provided on March 12, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe train-of-four (TOF) testing provided intraoperatively on March 10, 2020 billed with code 95999.You asked the Planto pay forthe TOF testing as billed. You say that this should be paid.The Plandenied your request. The Plansaysthe code used for this service is not valid.The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. In this case, payment was made for intraoperative neuromonitoring. TOF testing is an integral part of this service. As such, it is considered bundled and cannot be separately paid.Therefore, we decided that the Plandoes not haveto pay forthe train-of-four (TOF) testing provided intraoperatively on March 10, 2020 billed with code 95999.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRFA.You asked the Plan to pre-approvethe RFA. You say that you would like reconsideration because this service will help with your back pain and reduce your dependence on opioids.The Plan denied your request. The Plan says you received 75% relief from the second set of medial branch blocks.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found request does not meet the LCD requirement of both diagnostic sets producing greater than 80% pain relief. You achieved 75% relief with the second set of branch blocks.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the RFA have not been met.Therefore, we decided that the Plan does not have to pre-approveRFA.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided to
the enrollee from April 6, 2020, through May 6, 2020.
You asked the Plan to pay for the CGM supplies. You say that this was billed correctly. The Plan denied your
request. The Plan says that the medical records from the attending physician do not document frequency of
insulin dosing, nor direction on glucose monitoring.
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 documentation does not indicate that the enrollee performs blood
glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that
the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided to the enrollee from
April 6, 2020, through May 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by Marshall County Ambulance on July 29, 2020.You asked the Plan to pay forthe ambulanceservices. You say that you fell in the bathtub and the medics treated you in place.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 July 29, 2020. 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 forthe ambulance services provided by Marshall County Ambulance on July 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe neurostimulator implantation and imaging guidance provided on June 25, 2020.You asked the Plan to waive the copayment forthe neurostimulator implantation and imaging guidance. You say that the x-ray was done on the same day as surgery. You say that you already paid $350.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 $350 copayment for each Medicare-covered visit to an in-network outpatient hospital facility and a $60 copayment for Medicare-covered x-rays and ultrasounds.You have been asked to pay a $350 copayment for the neurostimulator implantation and a $60 copayment for the imaging guidance. The neurostimulator implantation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The imaging guidance 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 forthe neurostimulator implantation and imaging guidance provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered on September 21, 2020.
You asked the Plan to waive the copayment for these services. You say that this was a routine exam without any eye problems. 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 $40 copayment for each office visit to other vision care providers that are not your POC.
Review of the file shows that you received a diagnostic eye exam on September 21, 2020. The records show that you were seen for cataracts and inflammation of the eyelids and eyes. You have been asked to pay a $40 copayment for these services. These services fall within the office visit to other vision care providers that are not your POC 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 eye exam rendered on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent inpatient hospital care(99232) provided September 4, 2019.You asked the Plan to pay forsubsequent inpatient hospital care. You say that please reprocess the claim for payment based on these extensions in place for COVID-19.The Plan denied your request. The Plan says the time limit for filing had expired.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 subsequent inpatient hospital care was not filed until October 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forsubsequent inpatient hospital care(99232) provided September 4, 2019.