Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99239).

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 99239 is "Hospital discharge day management; more than 30 minutes."

We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not support that more than 30 minutes of discharge day management services were provided on the date of service in question. 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 the services (99239).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose test strips (A4253) and sensors for a CGM (A9276).

You asked the Plan to pay for blood glucose test strips and sensors for a CGM. You say that you have been using these items for several years. The Plan denied your request. The Plan says rules for payment have not been met.

Regarding the request for blood glucose test strips:

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, blood glucose test strips (A4253) were reported with the GY modifier. The GY modifier is added to claims in which the item or service is statutorily excluded. Based on this information, we decided that Medicare rules for coverage of blood glucose test strips have not been met. Therefore, we decided that the Plan does not have to pay for blood glucose test strips (A4253).

Regarding the request for sensors for a CGM:

The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM are non-covered.

In this case, the requested sensors for a CGM are for a non-therapeutic CGM. Supplies and accessories for non-covered items are not separately payable. Medicare rules for coverage of sensors for a CGM have not been met.

Therefore, we decided that the Plan does not have to pay for sensors for a CGM (A9276).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the right to recover for services provided to eligible beneficiaries is not extinguished by specific plan requirements. The Plan denied your request. The Plan says this service was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim was not billed with the required revenue code. Therefore, we decided that the Plan does not have to pay for laboratory services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 surgical extractions (D7210).

You asked the Plan to pay for the dental services. You say that you called the Medicare customer service. You say that you were advised that extractions are covered up to $500 per year. The Plan denied your request. The Plan says surgical extractions are not listed as covered services. The Plan also says that any services not listed are not covered.

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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the 2 surgical extractions (D7210).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray.

You asked the Plan to pay for the chest x-ray. You say that the enrollee's hospice election was revoked, when they were admitted as an inpatient. 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. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the chest x-ray.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable imaging services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. In this case, POS code 31 would indicate that the enrollee was in a Part A covered stay. If that were the case, then the setup and transport would not be billable by the provider, but by the SNF. This means that POS code 31 is not appropriate in this case. The correct POS code would be 32, which indicates a non-covered SNF stay. 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 the portable imaging services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the
physician's 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 physician's services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to reduce the cost-sharing for ambulance transportation.

You asked the Plan to reduce the cost-sharing for ambulance transport. You say that it is your understanding that your copayment for ambulance service is $270. The Plan denied your request. The Plan says that the deductible 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. Your contract with the Plan says that the deductible does not apply to ambulance services because ambulance service is a transportation service. Your contract with the Plan says that enrollees pay $270 copayment per one way trip for ambulance services.

The Plan says you must pay $421.25 deductible amount for ambulance transport. Based on the Plan contract, however, you cannot be asked to pay more than $270 copayment for ambulance transport per your appeal request. Therefore, we decided that the Plan has to reduce the cost-sharing for ambulance transportation.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone marrow biopsy.

You asked the Plan to waive the copayment for the bone marrow biopsy. You say that you did the test without being told the cost. You say that you don't understand why you were charged $250. The Plan denied your request. The Plan says the copayment applied 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 $250 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $250 copayment for the bone marrow biopsy. The bone marrow biopsy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 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 for the bone marrow biopsy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140).

You asked the Plan to pay for the dental service. You say that it had been 4 months since your previous appointment. You say that this was for another problem. You also say that maybe code D0140 is not correct. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee.

You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan says the DRG was downgraded and can be paid at DRG 378.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 871 is defined as "SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MAJOR COMPLICATION OR COMORBIDITY (MCC) - MARKET SIZE, PREVALENCE, INCIDENCE, QUALITY OUTCOMES, TOP HOSPITALS & PHYSICIANS."

In this case, you billed the services provided with DRG 871. 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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review has determined that the clinical indicators for sepsis were not supportive. DRG 378 was paid and is upheld. Therefore, the review for billed DRG 871 was denied based on CMS guidance.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 871. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay some for the bone graft for ridge preservation (D7953) and the guided tissue regeneration (D4266).

You asked the Plan to pay some for the dental services. You say that tooth # 30 became infected. You say that you already had tooth # 31 extracted. You say that you will need an implant in the future so that you are able to chew your food properly. You say that you needed the bone replacement graft so that you are able to get an implant in the future. You also say that you would like a portion of this service to be covered. The Plan denied your request. The Plan says bone replacement graft is not a covered benefit. The Plan also says that guided tissue regeneration is not listed as a covered service.

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 some for the bone graft for ridge preservation (D7953) and the guided tissue regeneration (D4266).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791).

You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says this claim was filed more than a year after the service was provided.

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 a psychiatric diagnostic evaluation was not filed until October 12, 2020. 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 a psychiatric diagnostic evaluation (90791).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely.

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 the anesthesia services was not filed until October 27, 2020. 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 anesthesia services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture (D5820).

You asked the Plan to pay for the dental item. You say that you had tooth decay and needed for the tooth to be extracted. You say that you needed the interim partial denture to prevent the adjoining teeth from moving and causing more problems. The Plan denied your request. The Plan says interim partial denture is not listed as a covered service.

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. An interim partial denture is different from a standard partial denture, it is meant to be temporary. The Evidence of Coverage clearly states that temporary procedures are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the interim partial denture (D5820).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the applications of multi-layer compression systems.

You asked the Plan to waive the copayments for the applications of multi-layer compression systems. You say that you feel that the provider was not located within a hospital and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 345 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

The record shows that the enrollee received the applications of multi-layer compression systems at an outpatient hospital facility. The applications of multi-layer compression systems are considered outpatient surgical procedures. Therefore, the enrollee is responsible to pay the total allowed amount of $1,837.13, which is less than the total copayment amount.

The enrollee has been asked to pay $1,837.13 for the applications of multi-layer compression systems. The applications of multi-layer compression systems fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the applications of multi-layer compression systems.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you thought that all copayments would be waived due to COVID-19 and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.

You received a Medicare Part B drug. Medicare Part B drugs are not included in the waiver. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $78.40 and 20% of that is $15.68.

You received a Medicare Part B drug. Medicare Part B drugs are not included in the waiver. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $78.40 and 20% of that is $15.68.

The total amount you owe is: $31.36.

You have been asked to pay the total coinsurance amount of $31.36 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing.

You asked the Plan to pay for the ConfirmMDx testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.

We looked at the file and Medicare rules. Review of the file does not support that the enrollee has had one negative prostate biopsy within 24 months and increasing prostate specific antigen levels. The enrollee had one previous prostate biopsy and ConfirmMDx was done at the same time. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Combinatorial Pharmacogenomics (CPGx) testing.

You asked the Plan to pay for GeneSight Psychotropic Combinatorial Pharmacogenomics testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that the present evidence does not clearly demonstrate that routine PGx testing for the purpose of medication selection offers a benefit over selection of medications based on contemporary evidence-based medication selection protocols.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GeneSight Psychotropic Combinatorial Pharmacogenomics testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic Combinatorial Pharmacogenomics (CPGx) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided by an OON provider.

You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating
provider. The Plan says that the referring provider is also out-of-network.

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 skilled nursing services provided by an OON provider.