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

We decided that the Plan does not have to pay for the CxBladder assay (0013M) provided on March 2, 2021.
You asked the Plan to pay for the CxBladder assay. You say that you would like reconsideration because this
testing was medically necessary. The Plan denied your request. The Plan says the requested testing does not
meet Medicare criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that for the CxBladder assay coded as 0013M , noncoverage
was reaffirmed by Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CxBladder assay have not been met. Specifically, Medicare has reaffirmed non-coverage for
the CxBladder assay billed with CPT code 0013M. Therefore, we decided that the Plan does not have to pay for
the CxBladder assay (0013M) provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vionic brand diabetic arch support shoes.

You asked the Plan to pre-approve the Vionic brand diabetic arch support shoes. You say that this item is medically necessary for your pain. The Plan denied your request. The Plan says this item is non-covered by Medicare.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order and relevant medical records which support medical necessity for the supplies requested in this case. Specifically, the Plan reached out to your provider and confirmed that they would not be ordering this item as it was a non-covered Medicare item. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve the Vionic brand diabetic arch support shoes.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport services provided on
April 2, 2021.
You asked the Plan to waive the copayment for ambulance transport services. You say that you did not ask for
an ambulance. 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 $125
copayment per day for Medicare-covered ambulance round-trip services.
You have been asked to pay $125 copayment for ambulance transport services. Ambulance transport services
fall within the Ambulance 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
ambulance transport services provided on April 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheelchair you rented and the back and seat cushions you purchased on March 2, 2021.
You asked the Plan to waive the coinsurance for the wheelchair and cushions. You say that you are being overcharged for this rental. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the wheelchair and cushions. Medicare sets the rates for payment of durable medical equipment. We confirmed that the Medicare-allowed rate for the back cushion
you received is $187.46, the allowed rate for the seat cushion is $43.97, and the allowed rate for the rental of the wheelchair is $47.94. That is a total Medicare-allowed rate of $279.37. Your 20% coinsurance obligation of that amount equals $55.87. This is the amount you are currently being charged for these three items. 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 coinsurance for the wheelchair you rented and the back and seat cushions you purchased on March 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 29, 2021.

You asked the Plan to pay for the dental services. You say that there are no network providers in your area. The Plan denied your request. The Plan says the claim processed correctly.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The file shows that a biological dressing and an unspecified oral procedure was provided. Although the Plan offers a dental benefit in excess of Medicare coverage, the services are not among those covered under this benefit.

The file shows that a limited oral evaluation was provided by an out-of-network provider. The Plan paid for the allowed amount for the exam. You are responsible for the difference between the billed amount and the allowed amount.

You also received dental extractions. You were charged a 50% coinsurance. You were also charged the difference between the billed amount and the allowed amount. We looked at the file, and Medicare rules. If you choose to see an out-of-network dentist, you might be billed for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to further pay for the dental services provided on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the assay of natriuretic peptide provided on January 4, 2021.
You asked the Plan to pay for the assay of natriuretic peptide. 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 a covered benefit.
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 assay of natriuretic peptide test at issue in this appeal was 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 the assay of natriuretic peptide provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on May 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not referred by a network provider or rendered in a participating facility. The services were not urgent or emergent and were not approved of in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from May 6, 2021, to May 10, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment 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 per day for days 1-5 for inpatient hospital services. 

Records show that you were in the hospital for four days. You have been asked to pay a $350 copayment per day for the inpatient hospital services. 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 inpatient hospital services you received from May 6, 2021, to May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, porcelain fused to high noble metal (D2750) tooth #17 provided October 9, 2020.

You asked the Plan to pay for the dental services. You say that you are appealing because you needed a crown. The tooth was good, and the dentist did not want to extract it. The Plan denied your request. The Plan says porcelain/ceramic crowns are not covered for molar teeth.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that cosmetic crowns, such as resin-based, noble metals, and porcelain, and pontics are not a covered benefit for molar teeth. Crowns on molar teeth are limited to base metal materials. You can find this information on page 108 of the Plan's 2021 Evidence of Coverage.

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 crown, porcelain fused to high noble metal (D2750) tooth #17 provided October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of gastrostomy or cecostomy (or other colonic) tube services coded 49450 provided on February 26, 2021.
You asked the Plan to pay for the replacement of gastrostomy or cecostomy (or other colonic) tube services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 49450 is replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.
We find that CPT code 49450 is not supported in the medical record. Specifically, the documentation shows that this service is considered as being part of the global surgical package of the initial procedure code 36581 (Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access) billed by the same provider for date of service February 22, 2021. Based on this information, we decided that Medicare rules for coverage of the replacement of gastrostomy or cecostomy (or other colonic) tube services have not been met. Therefore, we decided that the Plan does not have to pay for the replacement of gastrostomy or cecostomy (or other colonic) tube services coded 49450 provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this will allow an aid to move you to the
handicapped shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment without transport
(A0998) provided on December 10, 2020.
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you would
like reconsideration because you did not need to go to the hospital. The Plan denied your request. The Plan says
ambulance services without transport are not covered.
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 December 10, 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 response and treatment without
transport (A0998) provided on December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (22515, 22514) provided February 17, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 22515, & 22514 are not supported in the medical record. Specifically, the documentation supports T12(thoracic) and L2(Lumbar) Kyphoplasty. CPT 22514 is inappropriate to code for this procedure. There is a more appropriate code to report. CPT 22515 would not be covered, when the primary code is incorrectly reported.
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (22515, 22514) provided February 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of the lower extremity veins (93970) rendered by the out-of-network (OON) provider on January 15, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. 
The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the duplex scan of the lower extremity veins (93970) rendered by the out-of-network (OON) provider on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided April 13, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you would like the claim reprocessed and paid. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.

You asked the Plan to pre-approve a raised toilet seat. You say that this will help you go to the bathroom and ease your pain. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. 

While a raised toilet seat may be appropriate for G. Sandoval, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital services rendered on April 22, 2021 and April 23, 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 procedure code 99233 is not separately payable.

The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 

We looked at the file and Medicare rules. The file shows that the Plan previously paid for hospital physician services for this enrollee from the same provider group for the same date of service. 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 subsequent hospital services rendered on April 22, 2021 and April 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent nursing facility care provided on September 11, 2020.
You asked the Plan to pay for subsequent nursing facility care (99309). You say that the payment for the medical care provided to the enrollee is incorrect. The Plan denied your request. The Plan says that the claim was untimely because it was filed more than 180 days from the date of service.
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 nursing facility care (99309) was filed on March 15, 2021. This means that more than one calendar year from the date of service had not passed before a claim was filed. Therefore, we decided that the Plan has to pay for subsequent nursing facility care provided on September 11, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrodes rendered on June 28, 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 procedure code A4556 is not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are
bundled/excluded codes.
We looked at the file and Medicare rules. Billed procedure code A4556 (electrodes, per pair) has a status
indicator of P and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for
the electrodes rendered on June 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on November 24, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not support a comprehensive history, comprehensive examination and high medical decision making. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the surgical placement of implant body: endosteal implant (D6010) provided March 18, 2021.

You asked the Plan to provide additional payment for the endosteal implant. You say that you do not agree with the amount you have been reimbursed. The Plan denied your request. The Plan says you have been correctly reimbursed 50% of the Medicare payment amount.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the endosteal implant with 50% coinsurance multiplied by the Medicare payment rate for participating providers.

We looked at the file and Medicare rules. In this case you were reimbursed 50% of the Medicare payment rate for the service at issue. You may pay more when you receive services from an out-of-network provider. Therefore, we decided that the Plan does not have to provide additional payment for the surgical placement of implant body: endosteal implant (D6010) provided March 18, 2021.