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

We decided that the Plan does not have to waive the copayment for laboratory testing (82947, 88307) provided on September 14, 2020.

You asked the Plan to waive the copayment for laboratory testing. You say that you were only told that you would owe the $225 surgery copayment. The Plan denied your request. The Plan says this 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 $20 copayment for laboratory services. 

You have been asked to pay a $15.72 copayment for laboratory testing because the allowed amount is less than $20. 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 laboratory testing (82947, 88307) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe detailed and extensive oral evaluation (D0160), cone beam CTcapture (D0364), apicoectomy (D3410), retrograde filling (D3430), bone graft in conjunction with periradicular surgery (D3428), first intraoral X-ray (D0220), and each additional intraoral X-ray (D0230) provided on September 16, 2020.You asked the Plan to pay forthe detailed and extensive oral evaluation, cone beam CT capture, apicoectomy, retrograde filling, bone graft in conjunction with periradicular surgery, first intraoral X-ray, and each additional intraoral X-ray. You say that the services provided were medically necessary to treat your condiiton.The Plan denied your request. The Plan says the detailed and extensive oral evaluation, cone beam CT capture, apicoectomy, retrograde filling and bone graft in conjunction with periradicular surgery are not covered benefit. The Plan also says that you have exhausted your benefit for intraoral X-rays.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 intraoral X-rays once per calendar year. We lookedat the file and Medicare rules. The file indicates that they last covered intraoral X-rays in July 2020. Therefore, you had exhausted your benefit for intraoral X-rays until July 2021. Based on this information, we decided that the Plan's rules for coverage of first intraoral X-ray and each additional intraoral X-ray have not been met.Though the Plan offers a dental benefit in excess of Medicare coverage, the detailed and extensive oral evaluation, cone beam CT capture, apicoectomy, retrograde filling, bone graft in conjunction with periradicular surgery, first intraoral X-ray, and each additional intraoral X-rayare not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe detailed and extensive oral evaluation (D0160), cone beam CT capture (D0364), apicoectomy (D3410), retrograde filling (D3430), bone graft in conjunction with periradicular surgery (D3428), first intraoral X-ray (D0220), and each additional intraoral X-ray (D0230) provided on September 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic sigmoidoscopy (45330) provided September 22, 2020.You asked the Plan to pay forthe diagnostic procedure. You say that you are appealing this decision on the basis of the procedure was for prevention. According to the medical benefits chart, the procedure is covered for a screening exam.The Plan denied your request. The Plan says there is a $750 deductible and a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facilityThe rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible. This is the amount you have to pay out of pocket before the plan will pay their share for covered medical services. Until you have paid the deductible amount, you must pay the full cost of covered services. There is a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility for Outpatient hospital services.The item or service you asked the Plan to pay for falls within the benefit category Outpatient Hospital Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductibleand $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility for Outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic procedure was received on September 22, 2020.Therefore, we decided that the Plan does not have to pay forthe diagnostic sigmoidoscopy (45330) provided September 22, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran aminophylline injection with CPT code J0280 provided on August 19, 2020.You asked the Plan to pay forCPT code J0280. You say that the medical records support the billing of CPT code J0280 provided on August 19, 2020.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code J0280 provided on August 19, 2020.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 J0280 is injection, aminophylline, up to 250 mg.We find that CPT code J0280 is not supported in the medical record. Specifically, there is no documentation provided showing that this drug and amount was administered on August 19, 2020. Based on this information, we decided that Medicare rules for coverage of CPT code J0280 have not been met.Therefore, we decided that the Plan does not have to pay foran aminophylline injection with CPT code J0280provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eardrum testing using ear probe (92567) and air and bone conduction assessment of hearing loss and speech recognition (92557) provided on November 2, 2020.You asked the Plan to waive the copayment forthe eardrum testing using ear probe and air and bone conduction assessment of hearing loss and speech recognition. You say that you would like this copayment waived since you have had the service done multiple times.The Plan denied your request. The Plan says the copayment has applied correctly in this case.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Medicare-covered hearing services. You have been asked to pay a $35 copayment for the eardrum testing using ear probe and air and bone conduction assessment of hearing loss and speech recognition. The services provided fall within the Medicare-covered hearing 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 forthe eardrum testing using ear probe (92567) and air and bone conduction assessment of hearing loss and speech recognition (92557) provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - complete series of X-rays (D0210) provided on August 25, 2020.

You asked the Plan to pay for intraoral - complete series of X-rays. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the frequency limitation for this service has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers intraoral - complete series of radiographic images once every calendar year. 

We looked at the file and Medicare rules. The file indicates that you also received panoramic X-rays on August 25, 2020, which the Plan paid for. Based on this information, we decided that the Plan's rules for coverage of intraoral - complete series of radiographic images have not been met as you had exhausted your benefit. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of X-rays (D0210) provided on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a flowcytometry reading (88188) provided on September 3, 2020.

You asked the Plan to pay for a flowcytometry reading. You say that this is separately payable. The Plan denied your request. The Plan says this cannot be paid without a 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. In this case, we have confirmed that code 88188 has a Column One/Column Two relationship with code 88189, which was billed on a separate claim by the same provider, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a flowcytometry reading (88188) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual wellness visit (G0439) provided on September 22, 2020.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says you have exhausted the allowable benefit for this service.The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.Therefore, we decided that the Plan does not have to pay forthe annual wellness visit (G0439) provided on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is expected to make measurable
improvements with this level of care. The Plan denied your request. The Plan says the enrollee's care is not
complex, and he does not need a team of providers.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our physician reviewer found
that the enrollee was admitted to the acute hospital for MRSA bacteremia and osteomyelitis of the thoracic
spine. He will require twice daily intravenous antibiotics for approximately 5 weeks. His medical conditions
are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital
inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehab program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have topay forthe wrist x-ray provided on December 17, 2019.You asked the Plan to pay forthe wrist x-ray. You say that you would like this claim reprocessed for reimbursement.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on December 16, 2019. The services in question were provided before the end ofthat month.Therefore, we decided that the Plan does not have to pay forthe wrist x-ray provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvea microprocessor-controlled ankle-foot system coded as L5973.You asked the Plan to pre-approvethe L5973 microprocessor ankle/foot component. You say that the requested items are needed. The enrollee is active and needs this type of foot to be able to participate in his usual activities.The Plan denied your request. The Plan says the notes do not indicate why a microprocessor foot is medically necessary. The notes do not show why a mechanical prosthetic foot cannotmeet the member's needs. The request for a microprocessor foot exceeds the member's needs.The Plan follows Medicare rules. Medicare rules say that an L5973 ankle/foot is only covered for enrollees who are at a functional level of at least 3. 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 L5973 microprocessor ankle/foot component. Our reviewer says that the documentation does not support the medical necessity of the requested component. Our physician reviewer found the treating medical practitioner progress notes do not support that this patient is a Level 3 ambulator; therefore, the L5973 component exceeds the patient's needs.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 L5973 microprocessor ankle/foot component have not been met.Therefore, we decided that the Plan does not have to pre-approvea microprocessor-controlled ankle-foot system coded as L5973
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea low-load prolonged-duration stretch device for the enrollee.You asked thePlan to pre-approvethe device. You say that this is medically necessary.The Plan denied your request. The Plan says this is considered experimental, investigational, and not covered by the plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member therefore the requested E1800 brace is not medically necessary. There is insufficient evidence in the peer-reviewed published medical literature concerning the effectiveness of low-load prolonged-duration stretch device/hinged elbow brace for this enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe device have not been met.Therefore, we decided that the Plan does not have to pre-approvea low-load prolonged-duration stretch device for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services coded 99292 provided on May 10, 2020.You asked the Plan to pay forthe critical care services. 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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service).We find that CPT code 99292 is not supported in the medical record. Specifically, three units of this code were billed. The documentation does not support the unitsbilled. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay forthe critical care services coded 99292 provided on May 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe surgical removal of the right breast implant.You asked the Plan to pre-approvethe surgical removal of the right breast implant. You say that this service is necessary for the enrollee's condition.The Plan denied your request. The Plan says the surgery is considered cosmetic and will not be covered.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 surgical removal of the right breast implant. Our reviewer says that the service requested is cosmetic in nature. Our reviewer found the enrollee is a 66-year-old woman who underwent bilateral augmentation mammoplasty in 1989. The left breast implant has ruptured. The enrollee is interested in having both implants removed without replacement. Only the left implant is ruptured. Removal of the right implant would be done for cosmetic purposes.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 surgical removal of the right breast implant have not been met.Therefore, we decided that the Plan does not have to pre-approvethe surgical removal of the right breast implant
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursementforthe intraoral-periapical each additional radiographic image (D0230), periodic oral evaluation (D0120), and the dental cleaning (D1110) rendered by the out of network (OON) provider on November 9, 2020.You asked the Plan to issue reimbursement. 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 issue reimbursement forthe intraoral-periapical each additional radiographic image (D0230), periodic oral evaluation (D0120), and the dental cleaning (D1110) rendered by the out of network (OON) provider on November 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee was enrolled in a hospice program.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.SNF services from January 29, 2021 to January 31, 2021, were requested. The enrollee ended Medicare Hospice benefits on January 29, 2021. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) servicesfor this time frame.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran insertion of central venous access device (36561) performed on July 24, 2020.You asked the Plan to waive the copayment foran insertion of central venous access device. You say that this copayment is beyond your ability to pay.The Plan denied your request. The Plan says the correct copayment was 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 $275 copayment for each Medicare-covered surgery. You have been asked to pay a $275 copayment for an insertion ofcentral venous access device. An insertion of central venous access device falls within the "Outpatient surgery, including services provided at hospital outpatient facilities andambulatory 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 foran insertion of central venous access device (36561) performed on July 24, 2020.