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

We decided that the Plan does not have to pay an additional amount for the teeth extractions (D7210) received.

You asked the Plan to pay an additional amount for the teeth extractions. You say that you cannot afford the
dental bill. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 reimbursement is in
excess of that covered under this benefit. The Plan's maximum allowable charge for each tooth extraction was
$120. Each tooth extraction required a 50% coinsurance ($60). For services received out-of-network you will
be responsible for the cost between the Plan's maximum allowable charge and what the provider charged.
Therefore, we decided that the Plan does not have to pay an additional amount for the teeth extractions
(D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered.

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 December 14, 2020. A valid Waiver of Liability was not received until February 1, 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 physician services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services rendered.

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 G0299 is not payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.

We looked at the file and Medicare rules. Billed procedure code G0299 has a PC/TC indicator of 3 and no separate PC payment. 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 direct skilled nursing services rendered.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test.

You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the drug test. 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 a drug test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eye surgery.

You asked the Plan to pay for the eye surgery. The Plan denied your request. The Plan says non-emergent, nonurgent
services with out-of-network 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
eye surgery. 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 eye surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency anesthesia services rendered.

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 99140 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Billed procedure code 99140 has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia services rendered.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care.

You asked the Plan to waive the copayment for SNF care. You say that you thought Medicare would pay for the SNF services in full. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0.00 copayment per day for days 1 to 20, and a $178.00 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care up to an in-network maximum out-of-pocket amount of $6,400 for 2020. At the time this claim was processed, $2,810.92 of the $6,400 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 27 days, which were days 17 to 42 of the benefit period, resulting in a total copayment amount of $3,589.08 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $6,400 in-network maximum out-of-pocket amount for 2020.

You have been asked to pay a $0.00 copayment per day for days 1 to 20, and a $178.00 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care 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 SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found no acute medical complication,
hospitalization or acute change in functional status is documented in the available medical records. The
documentation does not support that the enrollee requires skilled nursing services or skilled therapy services to
be provided in the SNF setting. The enrollee does not require the necessary services on an inpatient basis, in a
skilled nursing facility setting. The enrollee's care needs can be met at a lower 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 SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of
intraoral x-rays provided by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you confirmed that this provider was in-network prior to the services being rendered. The Plan denied
your request. The Plan says these services were rendered by an OON provider. The Plan also says that services
performed by an OON provider are not covered because your healthcare plan does not have OON 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
covered when they are received OON. The record shows that you called the Plan to verify plan benefits and
provider eligibility prior to the date of service. You were provided with a list of eligible providers and dental
plan benefits. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation
and complete series of intraoral x-rays provided by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) rendered.

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 95822 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 95822 is electroencephalogram (EEG); recording in coma or sleep only.

We find that CPT code 95822 is not supported in the medical record. Specifically, there is no documentation of an EEG recording in coma or sleep. 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 electroencephalogram (EEG) rendered.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide a positron emission tomography (PET) scan.

You asked the Plan to provide an Axumin Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). You say that the enrollee needs a PET scan and time is crucial. The Plan denied your request. The Plan says the clinical value and effectiveness of an Axumin PET scan in the setting of newly diagnosed prostate cancer has not been demonstrated in the peer reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.

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 provide an Axumin Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815). Our reviewer says that a PET scan is not reasonable and medically necessary. Our physician reviewer found this patient has a high-risk prostate cancer and staging with a bone scan and cat scan are recommended. There are no records that these have been performed. A PET scan is not indicated for initial stating of prostate cancer. Axumin PET scan is recommended in men suspected of recurrent prostate cancer but this patient is newly diagnosed. The service is not reasonable or medically 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 an Axumin Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) have not been met. Therefore, we decided that the Plan does not have to provide a positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on July 30, 2020.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says nursing care services requires pre-approval prior to rendering the service, in addition, the Plan requires the utilization of in network providers unless the plan pre-approves out of network services in non-emergent situations. The provider did not make attempts to verify the member's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent services.

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 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 subsequent nursing facility care provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 10, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 laboratory services. 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 laboratory services provided on October 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied codes remain 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.

We find that CPT code 23650, 99152, and 99285 are not supported in the medical record. Specifically, these
codes were billed. The records show that the codes were rendered. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (99153).

You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan
denied your request. The Plan says these services are not separately 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 CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 has a
Professional Component (PC)/Technical Component (TC) indicator of 3 per the 2020 National Physician Fee
Schedule. The enrollee was treated as an inpatient. Payment for this service is included in the facility payment.
Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met.
Therefore, we decided that the Plan does not have to pay for an ultrasound (99153).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance services (A0429) and ground mileage (A0425) provided August 14, 2020.

You asked the Plan to pay for the ambulance services. You say that you were sent to the hospital at the request of the administrator of the assisted living home. The Plan denied your request. The Plan says the presence of the GY modifier indicates that this is not eligible for payment.

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 find that CPT code A0429 and A0425 is not supported in the medical record. Specifically, the claim was billed with the GY. Providers and suppliers use GY and GX modifiers to indicate that services or items are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance services (A0429) and ground mileage (A0425) provided August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine.

You asked the Plan to pay for the shingles vaccine. You say that this vaccine should be a covered service. The Plan denied your request. The Plan says the shingles shot is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine.

Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power elevating leg rests and an electronic connection.

You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says there is no medical need to control two power options through the joystick, and you do not need power leg lifts.

The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested items. Our physician reviewer found that you do not have a musculoskeletal condition, the presence of a cast or brace which prevents 90-degree flexion at the knee, significant edema of the lower extremities that requires an elevating leg rest, or requires a reclining back on the wheelchair. Your strength and function in the right upper extremity supports that you can control any power options through their own individual switches.

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 requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve power elevating leg rests and an electronic connection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using the requested medically necessary items with benefit. The Plan denied your request. The Plan says there was no documentation of a video or telephonic visit by the physician to warrant the codes billed.

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 pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the bilateral knees. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis have not been met. Furthermore, the requested suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered.

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 must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.

We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95885, 95908, 95937) provided
June 24, 2020.

You asked the Plan to pay for the neuromonitoring 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 codes 95885, 95908, & 95937 are not supported in the medical record. Specifically, the
technical report provided did not include sufficient information to determine if the CPT codes billed were
performed. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring
services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring
services (95885, 95908, 95937) provided June 24, 2020.