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

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from May 13, 2021, to June 12, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that the device was recalled so you should not owe a copayment. 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 DME and related supplies. 

You received DME and related supplies provided from May 13, 2021, to June 12, 2021. The total allowed amount is $94.95 and 20% of that is $18.99.

You have been asked to pay the total coinsurance amount of $18.99 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 DME and related supplies provided from May 13, 2021, to June 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive pharmacogenomics panel (81105, 81112, 81225, 81226, 81227, 81230, 81240, 81241, 81291, 81355) provided on January 29, 2021.

You asked the Plan to pay for a comprehensive pharmacogenomics panel. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. A panel constitutes a single procedural service, so one code must be submitted for the panel.

We find that CPT codes 81105, 81112, 81225, 81226, 81227, 81230, 81240, 81241, 81291, and 81355 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a comprehensive pharmacogenomics panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive pharmacogenomics panel (81105, 81112, 81225, 81226, 81227, 81230, 81240, 81241, 81291, 81355) provided on January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on April 23, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is 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. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 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 the services (70450) provided on April 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension kit(S1015) and infection control supplies (S8301) provided on January 27, 2021.

You asked the Plan to pay for the IV tubing extension set and infection control supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes S1015 and S8301 have a status indicator of I and are not valid for Medicare purposes.

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 S1015 and S8301 are not supported in the medical record. Specifically, per the Physician Fee Schedule, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set and infection control supplies. have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension kit(S1015) and infection control supplies (S8301) provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 12, 2021, and April 20, 2021.

You asked the Plan to pay for the services provided. You say that you are disappointed with your plan. The Plan denied your request. The Plan says the claims processed correctly.

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 file shows that you received a diagnostic consultation on April 12, 2021. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this benefit.

The file shows that you received endodontic therapy services on April 20, 2021. You were charged a 50% coinsurance. You were also charged the difference between the billed amount and the allowed amount. We found no exception which would require the Plan to further pay for the dental services at issue. Therefore, we decided that the Plan does not have to pay for the dental services provided on April 12, 2021, and April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x2), and bone replacement grafts (D7953 x2) provided on March 16, 2021.

You asked the Plan to pay for extractions, and bone replacement grafts. You say that you were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions, and bone replacement grafts have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. The record indicates that you had signed the financial agreement with the office with the understanding the provider is opted out of Medicare and that you have the option to get care from another provider. Therefore, we decided that the Plan does not have to pay for extractions (D7210 x2), and bone replacement grafts (D7953 x2) provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an OON provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 29, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you thought that copayments only applied to specialist visits. 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 a $100 copayment for diagnostic radiology. 

You have been asked to pay $10, which is less than the $100 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ultrasound provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of erupted tooth or exposed root (D7140)
provided April 22, 2021.
You asked the Plan to pre-approve the extraction of erupted tooth or exposed root. You say that you would like
this claim reprocessed based on not having met your annual maximum that would be covered. The Plan denied
your request. The Plan says this service is excluded from coverage.
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 pre-approve the
extraction of erupted tooth or exposed root (D7140) provided April 22, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a CustomNext-Cancer gene panel (81201, 81292, 81295, 81298, 81317, 81321, 88233) provided on August 25, 2020.

You asked the Plan to pay for a CustomNext-Cancer gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. A panel constitutes a single procedural service, so one code must be submitted for the panel.

We find that CPT codes 81201, 81292, 81295, 81298, 81317, 81321, and 88233 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of a CustomNext-Cancer gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a CustomNext-Cancer gene panel (81201, 81292, 81295, 81298, 81317, 81321, 88233) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve dermatology services. You say that this doctor is very thorough. You say that you were not satisfied with the in-network providers. The Plan denied your request. The Plan says these services can be provided within 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the diagnostic services provided February 13, 2020.
You asked the Plan to pay for the diagnostic services. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says that the claim was missing required
documentation.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the diagnostic services by a contract provider. The file does not show that the
plan provided notice that the diagnostic services would not be covered. Under Medicare rules, this means the
diagnostic services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the
diagnostic services provided February 13, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 29, 2021, to April 1, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford 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 a $275 copayment for days 1-5 for inpatient hospital care. 

You had an inpatient hospital stay from March 29, 2021, to April 1, 2021. Therefore, you are responsible to pay a $275 copayment for days 1-3 (March 29, 2021, to March 31, 2021). The total amount you owe is: $275 (copayment) x 3 (inpatient days) = $825. 

You have been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from March 29, 2021, to April 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth #13.
You asked the Plan to pre-approve the dental service. You say that the core build up is medically necessary for tooth # 13. The Plan denied your request. The Plan says core build up 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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth #13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator and implantable auricular neurostimulator.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679). You say that your goal is to help alleviate the enrollee's current pain and increase ability to participate in day to day activities. The Plan denied your request. The Plan says auricular devices are non-covered by Medicare as electrical acupuncture.
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 does not cover electrical devices behind the ear for acupuncture. Based on this information, we decided that Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679) have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous implantation of neurostimulator and implantable auricular neurostimulator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtampza.

You asked the Plan to pre-approve Xtampza. You say that the drug is medically necessary. The Plan denied your request. The Plan says this is a self-administered drug.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xtampza.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning provided on November 18, 2020.
You asked the Plan to pay for the services provided. You say that you have 3 cleanings per year. The Plan denied your request. The Plan says the claim was denied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. The file shows that the cleaning service at issue is the third cleaning you received in the plan year. Your plan only covers two standard cleanings per year. Based on this information, we decided that the Plan's rules for coverage of the have not been met. Therefore, we decided that the Plan does not have to pay for the dental cleaning provided on November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L0650, L1851, L2397) provided on November 5, 2020.

You asked the Plan to pay for orthotics. You say that these items are supported by the records. The Plan denied your request. The Plan says the submitted documentation is not sufficient to support these items.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted documentation does not include any delivery documents. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthotics (L0650, L1851, L2397) provided on November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2020 by a non-participating provider.

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 were rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 17, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 14, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on March 2, 2021.
You asked the Plan to pay for incontinence supplies. You say that the code in dispute was billed with a GY modifier and should have been denied as a non-covered service. The Plan denied your request. The Plan says the claim was appropriately denied per Medicare rules.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on March 2, 2021.
Please note that Maximus is hired to review the Plan's denial and to determine whether payment was appropriately denied. The adjustment of a denial code is not within our jurisdiction