Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), and prophylaxis (D1110) provided on February 2, 2021 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, and prophylaxis. You say that you were advised that this provider is in-network. The Plan denied your request. The Plan says this claim processed correctly. The Plan also says that these services were rendered by an OON provider.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), first intraoral periapical x-ray (D0220), and prophylaxis (D1110) provided on February 2, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical tooth extraction (D7210) provided on February 2, 2021.

You asked the Plan to pay for the extraction. You say that you believe this extraction was done because the provider broke your tooth during previous care. You feel it was either the providers fault or the services were billed incorrectly and that you are being taken advantage of. The Plan denied your request. The Plan says this type of extraction is not covered by your dental benefit. The Plan also says that you did not reach out to verify benefits with the Plan.

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 surgical tooth extraction (D7210) provided on February 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for needle biopsy of lung or chest tissue, accessed through the skin (CPT code 32405) provided on December 3, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a needle biopsy of lung or chest tissue, accessed through the skin (CPT code 32405) on December 3, 2020, by the outpatient department. You were asked to pay a $250 copayment for the outpatient surgery. Your 2020 EOC states that enrollees must pay a $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. 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 needle biopsy of lung or chest tissue, accessed through the skin (CPT code 32405) provided on December 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for needle insertion(s) without injection(s); 3 or more muscles (CPT Code 20561) and physical therapy services (CPT Code(s): 97110 and 97140) provided on May 6, 2020.
You asked the Plan to waive the copayment for the services. You say that you believe you should be charged for one copayment only per visit. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that on May 6, 2020, you had needle insertion(s) without injection(s); 3 or more muscles (CPT Code 20561) with a specialist/practitioner with a $35 copayment. Also, physical therapy services (CPT Code(s): 97110 and 97140) with a copayment of $35 which total $70 for the services received. 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 needle insertion(s) without injection(s); 3 or more muscles (CPT Code 20561) and physical therapy services (CPT Code(s): 97110 and 97140) provided on May 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.

You asked the Plan to pre-approve a lumbar epidural steroid injection. You say that the requested lumbar epidural steroid injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for a lumbar epidural steroid injection.

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 a lumbar epidural steroid injection. Our reviewer says that the enrollee does not meet criteria for a lumbar epidural steroid injection. Our physician reviewer found this enrollee is a morbidly obese woman who has chronic low back pain and a positive Straight leg raising test on the Right. She has a history of Breast cancer. The request is for an Epidural steroid injection. There is no imaging of the lumbar spine. There is no imaging of the lumbar spine documented. Therefore, the criteria of the LCD are not met, and the request is deemed at this point, not medically reasonable or necessary. 

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 lumbar epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0482) provided July 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services 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 G0482 is not supported in the medical record. Specifically, the Place of Service on the
claim (81, laboratory) does not match the Place of Service detailed in the records (11, office setting). Based on
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore,
we decided that the Plan does not have to pay for lab services (G0482) provided July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that lab tests were done for the samples received. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 16, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery services provided on December 15, 2020.
You asked the Plan to waive the cost share for the services provided. You say that your provider advised you they were in-network. The Plan denied your request. The Plan says the claim 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 50% coinsurance for out-of-network outpatient surgery. You have been asked to pay a 50% coinsurance for the out-of-network services provided. The services fall within the outpatient surgery 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 cost share for the outpatient surgery services provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted to a skilled nursing facility with history of stroke, dementia, protein calorie malnutrition and dysphagia. She has ongoing weakness. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.

You asked the Plan to pre-approve Genvisc. You say that the requested Genvisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Durolane, Gelsyn-3 and Synvisc/Synvisc-One first. The Plan says they have approved Gelsyn-3 and the provider agrees the enrollee can be switched to Gelsyn-3.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Genvisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Durolane and Synvisc/Synvisc-One first before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on January 26, 2021, by an
OON provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan
denied your request. The Plan says 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 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 laboratory work provided on January 26, 2021,
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on December 17, 2020.
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 office visit (99214) rendered by the out of network (OON) provider on December 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from October 26, 2020, to
December 21, 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 claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes,
HHAs must report one of the three Q codes (Q5001, Q5002, and Q5009).
We looked at the file and Medicare rules. The file shows that the claims were not billed with one of the
required Q codes. 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 home health services
rendered from October 26, 2020, to December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 30, 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 testing is not covered.
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 test at issue in this appeal, a cardiovascular risk assessment panel, 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 laboratory services rendered on July 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of non-tunneled central venous tube for infusion, chest x-ray, CT of thorax, CT of the abdomen and pelvis, laboratory services, routine ECG, hydration infusion, therapeutic IV infusion, prophylactic IV infusion, additional IV infusion, additional IV push diagnostic injection, critical care, clinical decision support mechanism, and injections provided on July 4, 2020.
You asked the Plan to pay for the insertion of non-tunneled central venous tube for infusion, chest x-ray, CT scans, laboratory services, routine ECG, IV infusions, additional IV push diagnostic injection, critical care, clinical decision support mechanism, and injections. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says these services would be covered by Original Medicare on the date of hospice election, until the first day of the following month in which hospice was revoked. The Plan also says that this request needs to be submitted to Original Medicare for reimbursement.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the insertion of non-tunneled central venous tube for infusion, chest x-ray, CT of thorax, CT of the abdomen and pelvis, laboratory services, routine ECG, hydration infusion, therapeutic IV infusion, prophylactic IV infusion, additional IV infusion, additional IV push diagnostic injection, critical care, clinical decision support mechanism, and injections provided on July 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 29, 2020.
You asked the Plan to pay for the laboratory 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 payable.
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 the laboratory services are not supported in the medical record. Specifically, there is no coverage
when laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered
part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for
the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health services rendered from January 8, 2020 to January 14, 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 not filed timely.
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 these services was not filed until February 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the inpatient mental health services rendered from January 8, 2020 to January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 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 the services are not covered.
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 37228-LT is revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. We find that CPT code 37228-LT is not supported in the medical record. Specifically, the operative report does not contain documentation of an open or percutaneous endovascular revascularization of a unilateral tibial or peroneal artery. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 37224-LT and 75716. Code 75716 is a column II code with a modifier indicator of 1 when billed with column I code 37224. Code 75716s was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the surgical services rendered on December 7, 2020.