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

We decided that the Plan does not have to pay for genetic testing provided on January 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you are the only provider who can provide these services. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer these services. The Plan says that 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for genetic testing provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the fluid circulating cold pad with pump provided on January 15, 2020.
You asked the Plan to pay for the fluid circulating cold pad with pump. You say that your doctor prescribed the fluid circulating cold pad with pump. The Plan denied your request. The Plan says that a fluid circulating cold pad with pump is not covered by Medicare or the Plan.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. the plan follows these rules. You were referred for the fluid circulating cold pad with pump by a contracted provider. The file does not show that the plan provided notice that the fluid circulating cold pad with pump would not be covered. Under Medicare rules, this means the fluid circulating cold pad with pump is considered approved by the plan. Therefore, we decided that the Plan has to pay for the fluid circulating cold pad with pump provided on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a surgical injection procedure provided on December 2, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that this was done at a doctor's office and not a hospital. The Plan denied your request. The Plan says the copayment amount 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 $395 copayment for outpatient surgery at an outpatient hospital. The rendering provider is considered to be an outpatient hospital facility; therefore, the outpatient hospital surgery copayment applies to this claim. You have been asked to pay $395 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 surgical injection procedure provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered on February 5, 2020.
You asked the Plan to waive the copayment for these services. You say that the services were a pre-operative visit and should have no copayment. 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 $10 copayment for each primary care doctor office visit for Medicare-covered services.
Review of the file shows that you received primary care doctor services on February 5, 2020. You had surgery on February 19, 2020 and the procedure had a 10-day pre-operative period, meaning that services between February 9, 2020 to February 19, 2020 were covered in the operative period. The services on February 5, 2020 were performed outside of the operative period. You have been asked to pay a $10 copayment for these services. These services fall within the primary care doctor office visit for Medicare-covered services 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 rendered on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services (T1019) provided from September 21, 2019 to September 25, 2019.
You asked the Plan to pay for the personal care services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says personal care services are not covered under the enrollee's Medicare Advantage benefit.
The Plan must follow Medicare rules. Medicare rules say that Custodial care is not covered. We looked at the file, the Plan's contract and Medicare rules. In this case, personal care services (T1019) were provided to the enrollee. Personal care services are considered custodial care, which includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and medications. Custodial care and personal care services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the personal care services (T1019) provided from September 21, 2019 to September 25, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optichamber MIS Diamond for the enrollee.
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit, as it does not meet the definition of durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the Optichamber MIS Diamond for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate lower partial denture (D5222) provided on
December 31, 2019.
You asked the Plan to pay for the immediate lower partial denture. You say that you were still covered under
your dental plan when you received the services. The Plan denied your request. The Plan says the immediate
partial denture is not listed as a covered service.
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 immediate partial denture is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
immediate lower partial denture (D5222) provided on December 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on November
21, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that this service should be
included in the stay at the nursing facility. The Plan denied your request. The Plan says that you are responsible
for your copayment.
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 $220
copay for each Medicare-covered one-way trip via ground ambulance.
You have been asked to pay a $215.42 copay for the ambulance transport. The ambulance transport falls within
the Medicare-covered one-way trip via ground ambulance benefit category. This means that you have been
asked to pay less than 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 copay for the ambulance transport provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental consultation (D9310) comprehensive oral exam (D0150) intraoral - complete series x-rays (D0210) dental extractions (D7140x13) deep sedation, each subsequent 15 minute increment (D9223) intravenous moderate (conscious) sedation, each subsequent 15 minute increment (D9243) therapeutic parenteral drugs (D9612) provided November 5, 2019.
You asked the Plan to pay for the dental services. You say that this work was done in order to have aortic aneurysm surgery. You request reimbursement for the medically necessary work of $3548 and fix the already paid amount to the dentures up to $2000. The Plan denied your request. The Plan says the annual maximum benefit has been exhausted.
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 are responsible for any amount above the dental coverage limit. You have been asked to pay $3548 for the dental services. The services fall within the Dental services 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 pay for dental consultation (D9310) comprehensive oral exam (D0150) intraoral - complete series x-rays (D0210) dental extractions (D7140x13) deep sedation, each subsequent 15-minute increment (D9223) intravenous moderate (conscious) sedation, each subsequent 15-minute increment (D9243) therapeutic parenteral drugs (D9612) provided November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on October 8, 2019.
You asked the Plan to pay for genetic screening tests. You say that the enrollee has a family history which
supports testing. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because these tests were screening in nature and not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, genetic screening tests, 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
for genetic screening testing provided on October 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee.
You asked the Plan to pre-approve the admission. You say that you are concerned about walking a certain
distance. The Plan denied your request. The Plan says skilled services are not required.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of
service criteria for an inpatient basis in a skilled nursing facility setting.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee needs a respiratory therapist to set her up at home and maintain her compliance daily. The Plan denied your request. The Plan says the service requested is available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a home ventilator to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152) provided on October 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
cannot be verified.
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 99152 is "Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older".
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 the use
of CPT code 99152 is not supported by the records provided. Our physician reviewer found that the records did
not indicate the presence of an independent trained observer intraoperatively for the billed services.
Additionally, there were no anesthesiology records documenting intraoperative monitoring of this patient
(including blood pressure, heart rate, respiratory rate, EKG, oxygen saturation) or medications administered.
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 pay for the services (CPT 99152) provided on October 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
February 8, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the copayment because the doctor did not treat you. The Plan denied your request. The Plan
says you have been charged the correct cost sharing 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 $90
copayment for each emergency room visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The medical record shows you were examined during your
emergency room visit.
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 emergency room visit provided on February 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-Ray examination provided on
December 20, 2019.
You asked the Plan to waive the copayment for X-Ray exam. You say that this was for a post-operative visit.
The Plan denied your request. The Plan says the copayment amount 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 $20
copayment per visit for X-Rays.
You have been asked to pay $20 copayment for X-Ray exam. X-Ray exam 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 an X-Ray examination provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar epidural injection provided on August 13, 2019.
You asked the Plan to pay for the injection. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are covered for the above indications. 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 injection. Our reviewer says that the requested lumbar injection was not medically reasonable and necessary. Our physician reviewer found that the enrollee was a then 77-year-old female with low back pain secondary to lumbar spinal stenosis, lumbar spondylosis, and lumbar degenerative disc disease with radiculopathy. She had an MRI on July 17, 2018, that demonstrated disc protrusion at L3-4 with moderate to severe spinal stenosis. The enrollee has been treated with medical therapy and received a right L4-L5 transforaminal epidural steroid injection on July 12, 2018. In this case, the requested injection is requested without guidance. The requested injection is not medically reasonable or necessary according to the coverage criteria established in the above LCD. 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 injection have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar epidural injection provided on August 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish, complete series of
intraoral x-rays, and comprehensive oral evaluation provided on December 31, 2019.
You asked the Plan to pay for the topical application of fluoride varnish, complete series of intraoral x-rays,
and comprehensive oral evaluation. You say that the Plan should have covered your other dental services
because you have additional dental coverage. The Plan denied your request. The Plan says topical application
of fluoride varnish is not a covered benefit. The Plan also says that your benefits for the complete series of
intraoral x-rays and comprehensive oral evaluation has been exhausted.
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, topical application of fluoride varnish
is not among those covered under this benefit. The contract clearly states that oral examinations and cleanings
are limited to two per calendar year. The record shows that you received problem focused limited oral
evaluations on March 8, 2019 and October 25, 2019, and your oral examinations and cleanings benefit was
then exhausted. The Plan contract also clearly states that complete intraoral series and panoramic film are each
limited to once every 60 months. The record shows that you received a complete series of intraoral x-rays on
November 15, 2018 and your complete intraoral series benefit has been exhausted. Therefore, we decided that
the Plan does not have to pay for the topical application of fluoride varnish, complete series of intraoral x-rays,
and comprehensive oral evaluation provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services rendered on November 7, 2019.
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 procedure codes 95909 and 95886 are not supported.
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 95909 is nerve conduction studies; 5-6 studies. The definition of code 95886 is needle electromyography of extremity with nerve conduction, amplitude and latency study. We find that CPT codes 95909 and 95886 are not supported in the medical record. Specifically, there is no documentation in the technical report of 5-6 nerve conduction studies to support code 95909 or documentation of needle electromyography done with nerve conduction to support code 95886. 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 for the monitoring services rendered on November 7, 2019.