Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on September 3, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 proof of delivery for the supplies provided in this case. 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 pay for the durable medical equipment provided on September 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 30, 2021.
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 January 30, 2021. 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 January 30,
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on December 24, 2020 by an OON provider.

You asked the Plan to pay for the home visit. You say that you provide urgent/emergent care in the home which does not require prior authorization, nor does it require a referral. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says that services are not covered by the enrollee's plan when performed by a non-participating provider.

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 the home visit provided on December 24, 2020 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on January 7, 2021 by an OON provider.
You asked the Plan to pay for the home visit. You say that the enrollee did not have many options to choose another provider in the area that was able to make home visits with an enrollee in his situation. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that the services were not referred by a network provider, 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided on January 7, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on March 19, 2021.
You asked the Plan to pay for the exam and x-rays. You say that your provider did not tell you these services
would not be covered, and you cannot pay these bills. The Plan denied your request. The Plan says these
services can only be covered once every three years, and the Plan previously paid for a comprehensive oral
evaluation and complete series of intraoral x-rays in September 2019. It has not been three years since these
services were previously provided, and therefore payment cannot be made.
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 can cover one
comprehensive oral evaluation every three years, and one complete series of x-rays every three years.
Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a
frequency that is not covered under this benefit. Documentation supports that the Plan has paid for both of
these services within the last three years, and your benefit for these services is currently exhausted. Therefore,
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code 80307) provided to the enrollee on February 5, 2021, by an out-of-network provider.

You asked the Plan to pay for the drug test. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 the drug test (CPT code 80307) provided to the enrollee on February 5, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910), and topical application of fluoride (D1206) provided on January 11, 2021.

You asked the Plan to pay for periodontal maintenance, and topical application of fluoride. You say that you have had services covered by this provider in the past, and nothing has changed. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance, and topical application of fluoride have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910), and topical application of fluoride (D1206) provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac monitoring (93042) provided November 20, 2020.
You asked the Plan to pay for the cardiac monitoring. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for this service was included in another CPT code 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. We find that CPT code 93042 is not supported in the medical record. Specifically, payment was issued for CPT code 93010, Diagnostic EKG, which included this service. Based on this information, we decided that Medicare rules for coverage of the cardiac monitoring have not been met. Therefore, we decided that the Plan does not have to pay for cardiac monitoring (93042) provided November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on July 6, 2020 to July 7, 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 99291 is 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of initial critical care spent on the patient.
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 critical care services rendered on July 6, 2020 to July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccination services represented by codes 90662, G0008, 90670 and G0009 provided on October 29, 2020.

You asked the Plan to pay for codes 90662, G0008, 90670 and G0009. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of codes 90662, G0008, 90670 and G0009.

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 90662 is Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use. The definition of code G0008 is Administration of influenza virus vaccine. The definition of code 90670 is Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use. The definition of code G0009 is Administration of pneumococcal vaccine.

We find that CPT codes 90662, G0008, 90670 and G0009 are not supported in the medical record. Specifically, the records provided did not show that these vaccines were provided during this visit. Based on this information, we decided that Medicare rules for coverage of codes 90662, G0008, 90670 and G0009 have not been met. Therefore, we decided that the Plan does not have to pay for the vaccination services represented by codes 90662, G0008, 90670 and G0009 provided on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on November 23, 2020.
You asked the Plan to pay for the maxillary partial denture. You say that a pre-authorization was sent to the Plan numerous times, and you contacted the Plan to make sure it had been received. You also say that this service is covered. The Plan denied your request. The Plan says a service authorization was not found. The Plan also says that there are no documents or x-rays to support that this denture is medically necessary.
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, there was no documentation submitted to support that the maxillary partial denture (D5213) is medically necessary. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture (D5213) provided on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigations (D4921) and topical fluoride varnish application (D1206) provided on February 26, 2021.

You asked the Plan to pay for the dental services. You say that you were told you would only owe the amount you paid on the date of service, and you feel you were misled by this dentist.The Plan denied your request. The Plan says they have agreed to pay for the periodontal scaling and root planing, however gingival irrigations and fluoride 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 gingival irrigations (D4921) and topical fluoride varnish application (D1206) provided on February 26, 2021.

Your complaint about the information and services provided by a Plan-contracted provider 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening provided on December 21, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. The documentation provided shows that the need for testing was initiated by the enrollee. The medical records do not show that the enrollee's treating physician requested the testing for treatment of a specific medical problem, or for the determination of a specific diagnosis. The test at issue in this appeal 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 the hereditary cardiovascular screening provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on November 30, 2020.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 physician/practitioner services/specialist. 

You have been asked to pay a $40 copayment for a specialist office visit. The correct copayment has been applied to the services provided. A specialist office visit falls within the physician/practitioner services/specialist 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 specialist office visit provided by a participating provider on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology examination of tissue (CPT code 88305) provided to the enrollee on February 3, 2021, by an out-of-network provider.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit before providing services to the enrollee as outlined on the enrollee's identification card.

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 the pathology examination of tissue (CPT code 88305) provided to the enrollee on February 3, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test.

You asked the Plan to pre-approve a nuclear stress test. You say that the information provided supports the
need for the requested service. The Plan denied your request. The Plan says the enrollee's clinical condition
does not meet the criteria for coverage. The Plan says that there is no documentation provided to indicate that
the enrollee would not be able to complete exercise treadmill study, nor is there evidence of an abnormal
resting ECG. The Plan says that the requested imaging study cannot be considered medically necessary.

The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is indicated for
diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by
drugs, bundle branch block, or left ventricular hypertrophy.

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 a nuclear stress test. Our reviewer says
that the criteria for coverage have not been met. Our physician reviewer found the chest pain is not well
described in the records but occurs all the time and has atypical features. The enrollee has no history of
established CAD, prior angina, prior MI or coronary revascularization procedures and she would be considered
low to intermediate risk for coronary artery disease. There is no report of EKG changes at baseline that would
make an EKG only stress test uninterpretable (paced rhythm, left bundle branch block, drugs effects or left
ventricular hypertrophy). There is no report of inability to exercise or orthopedic limitations to walking on a
treadmill which might necessitate a pharmacologic nuclear stress test. Therefore, the enrollee would not meet
criteria for nuclear stress testing in lieu of an initial exercise EKG stress test.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a nuclear stress test have not been met. Therefore, we decided that the Plan does
not have to pre-approve a nuclear stress test.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 19, 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. 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 October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency treatment of dental pain (D9110) provided on March 15, 2021.

You asked the Plan to pay for emergency treatment of dental pain. You say that the service was necessary because of pain. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for emergency treatment of dental pain (D9110) provided on March 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.

You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The
Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found that the additional requested therapy is not generally accepted as
specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The
enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively
performed only by a therapist, or by or under the supervision of a therapist. The enrollee should be able to
transition to an independent home exercise program. The requested services are not part of a maintenance
program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional PT visits.