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

We decided that the Plan has to pay for the home health aide services provided to the enrollee from November 
18, 2020, through March 24, 2021. 
 
You asked the Plan to pay for the home health aide services. You say that you have paid out of pocket costs for 
caregiving services and are seeking reimbursement. The Plan denied your request. The Plan says that the 
provider will need to submit the remaining claims to the health plan to be considered for processing. Then you 
or the enrollee can request reimbursement from the provider. The Plan states they do not have to pay for home 
health aide services provided to the enrollee during the listed dates of service; nor can reimbursement be 
approved. 
 
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 not made reasonable and diligent efforts to gather and forward to 
us information regarding their decision to deny your request. Specifically, the Plan has not provided any 
information as to why the facility claim would negate the member's request for home health reimbursement. It 
is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the home health 
aide services provided to the enrollee from November 18, 2020, through March 24, 2021.  
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from February 9, 
2021, to March 6, 2021.  
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you 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 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 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 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 out of network physician services provided from February 9, 2021, to March 6, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Section 150. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract 
says that the Plan covers certain dental services as a supplemental (extra) benefit. This benefit includes specific 
preventative and comprehensive services that are listed in the Plan's contract with unique procedure codes. 
Services and codes not listed are not covered. You can find this information on pages 4-77 to 4-82 of the Plan's 
2021 Evidence of Coverage (EOC).s not have to pay for four oral/facial photographic images (D0350) provided on 
April 21, 2021. 
 
You asked the Plan to pay for the photographic images. You say that you chose a recommended in-network 
provider and do not understand why these services are not covered. The Plan denied your request. The Plan 
says these services are not covered by your dental 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 four 
oral/facial photographic images (D0350) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202), chiropractic manipulative treatment (98941), x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) rendered by the out-of-network (OON) provider on January 4, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 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 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 office visit (99202), chiropractic manipulative treatment (98941), x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) rendered by the out-of-network (OON) provider on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment (A9300) purchased on August 10, 2020,
and September 4, 2020.
You asked the Plan to pay for fitness equipment. You say that your physical therapist recommended purchasing
the equipment to reduce back problems and avoid surgery.
You also say the equipment has reduced your pain and you were not aware of the specific dates of purchase in
order to be reimbursed. The Plan denied your request. The Plan says the fitness equipment was purchased
before October 1, 2020, is not eligible for reimbursement under the Plan's health and wellness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits
only The Plan contract for 2020 states that the Plan can pay up to $300 per calendar year toward your cost of a
membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in
wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1,
2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment
that you can use at home. Purchases made prior to October 1, 2020, do not qualify.
The Plan's rules for coverage of gym benefits have not been met because this purchase was made prior to the
Plan's policy changes that became effective on October 1, 2020. Therefore, we decided that the Plan does not
have to pay for fitness equipment (A9300) purchased on August 10, 2020, and September 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation (PTNS).
You asked the Plan to pre-approve the services. You say that this is medically necessary, as the therapy has decreased the enrollee's symptoms, and increased her qualify of life. The Plan denied your request. The Plan says this is not covered after reaching the maximum lifetime number of sessions.
The Plan must follow Medicare rules. Medicare rules say that the maximum lifetime number of sessions for percutaneous tibial nerve stimulation (PTNS) will be 45 total. The guidelines say that the maximum number of sessions for the requested therapy is 45. The enrollee has completed 45 sessions of PTNS. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous tibial nerve stimulation (PTNS).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on December 14, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests/panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. You are receiving appropriate care at the present acute care hospital and do not require services at the
LTACH that are not available at the acute care hospital where you are currently receiving care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Specifically, medically necessary
services are being obtained at your current level of care and you do not require any additional services at an
LTACH that you are not already receiving. This means admission into a LTACH is not medically necessary or
reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital
(LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reimbursement in the amount of $1101.36, he paid for a 
comprehensive exam and eyeglasses provided on December 8, 2020. 
 
You asked the Plan to pay for out of network vision services. You say that you were not satisfied with the Plans 
contract provider and chose to go out of network. The Plan denied your request. The Plan says you did not have 
prior authorization for out of network vision 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 area urgent care and pre-approved care. The 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 reimbursement in the amount of $1101.36, he paid 
for a comprehensive exam and eyeglasses provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

81381) provided on January 12, 2021.
You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. We find that CPT codes 81225, 81226, 81227, 81230, 81231, and 81381 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with one code. Based on this information, we decided that Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus gene panel (81225, 81226, 81227, 81230, 81231, 81381) provided on January 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0428) provided on April 4, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel this charge is too expensive and you cannot afford the cost. The Plan denied your request. The Plan says this claim was processed 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 $325 copayment for Medicare-covered ambulance services. 

You have been asked to pay a $325 copayment for the ambulance transportation. 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 ambulance transportation services (A0428) provided on April 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on February 15, 2021.
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for codes 0012M and 0013M for CxBladder. We looked at the file and Medicare rules. The testing at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on February 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78608).
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Medicare covers FDG PET scans when a patient meets diagnostic criteria for both fronto-temporal dementia (FTD) and Alzheimer's disease (AD) for differential diagnosis. 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 PET scan. Our reviewer says that the PET scan is not medically necessary. Our physician reviewer found there was no indication of a concern for FTD. A differential diagnosis is not needed 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 the PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78608).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021.

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 not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (unattended) (97014) provided
December 14, 2020 to December 23, 2020.
You asked the Plan to pay for the chiropractic services. You say that you are being charged a service you
shouldn't be for a chiropractic change in your benefit policy. The Plan denied your request. The Plan says this
service is not covered when rendered by a chiropractor.
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 for electrical stimulation (unattended) (97014) provided December 14, 2020 to
December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and accessories (K0861, E2361, E2377).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no increased tone or spasticity, and there is no requirement for a drive control interface other than a hand or chin-operated standard proportional joystick.
The Plan follows Medicare rules. Medicare rules say that a group 3 power wheelchair is covered if there is a qualifying diagnosis such as a neurological condition, myopathy, or a skeletal deformity. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there is no qualifying diagnosis for a group 3 power wheelchair. The occupational therapy notes reference a history of T5-7 syrinx; however, this is not noted in the physician documents. There are no objective imaging reports of this, or any evidence that it is causing a mobility deficit. There is no evidence of a spinal syrinx in the physician documentation. Ehlers Danlos is a connective tissue disorder. There is no evidence of a myopathy, a neurological condition, or a congenital skeletal deformity on the physician progress notes that indicate a qualifying Group 3 diagnosis. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power options and accessories (K0861, E2361, E2377).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vertebral augmentation (22515-51) provided on February 17, 2021.

You asked the Plan to pay for vertebral augmentation. You say that this was billed correctly. The Plan denied your request. The Plan says this was billed with an inappropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Modifier 51 should not be appended to add-on codes.

In this case, the CPT Code Manual definition of code 22515 is percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure). 

We find that CPT code 22515-51 is not supported in the medical record. Specifically, this is an add-on code and should not be billed with modifier 51. Based on this information, we decided that Medicare rules for coverage of vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pay for vertebral augmentation (22515-51) provided on February 17, 2021.