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

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) rendered on January 28, 2021.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 70544 is not separately payable.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 70544 and 70551. Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 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 magnetic resonance angiography (MRA) rendered on January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140), the filling (D2331), the prophylaxis
(D1110), and the comprehensive oral evaluation (D0150) provided on January 5, 2021.
You asked the Plan to pay for the dental services. You say that you told the provider that you did not want a
bill at the end of receiving services. You say that you did not have the money to pay for anything. You also say
that no one advised that the dentist you saw was out of network. The Plan denied your request. The Plan says
the provider in this case is out of network. The Plan says that dental services performed out of network are not
covered. The Plan also says that it is your responsibility to verify every new provider that you see prior to
receiving treatment.
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 and the services are listed as covered,
dental services performed out of network are not among those covered under this benefit. Therefore, we
decided that the Plan does not have to pay for the extraction (D7140), the filling (D2331), the prophylaxis
(D1110), and the comprehensive oral evaluation (D0150) provided on January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental surgery procedure (41899) and anesthesia for
intraoral procedures (00170).
You asked the Plan to pre-approve the dental surgery procedure and anesthesia. You say that you need these
services to be approved for coverage under your medical insurance. The Plan denied your request. The Plan
says these services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule.
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 dental surgery procedure and
anesthesia. Our reviewer says that the treatment indicated does not meet the criteria for coverage according to
the documentation provided. Our physician reviewer found according to the Medicare guidelines, the
treatment, care, filling, extraction or replacement of teeth or the supporting structures of the teeth are not
covered expenses. Our reviewer also found that according to your dental record and radiographs, the treatment
directly involves the teeth and dental supporting structures.
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 dental surgery procedure and anesthesia have not been met. Therefore, we
decided that the Plan does not have to pre-approve a dental surgery procedure (41899) and anesthesia for
intraoral procedures (00170).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio gene panel provided on December 7, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. The medical records show that the provider ordered a complete blood count (CBC), lipid panel, and urine culture testing. The records do not indicate the results of the provided gene panel would be used in the management of a specific medical problem. The test was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardio gene panel provided on December 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, and crown provided from December 1, 2020, to December 9, 2020.
You asked the Plan to pay in full for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, and crown. You say that you believe these services should be covered. The Plan denied your request. The Plan says according to the fee schedule for preventive services for these services, a total of $ 555.00 is approved to be reimbursed to you.
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 fee to be paid for the service provided will be the rate established by the Plan for that procedure. Therefore, we decided that the Plan does not have to pay in full for the comprehensive oral evaluation, complete series of intraoral x-rays, prophylaxis, and crown provided from December 1, 2020, to December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital physician visit provided on December 23, 2019.
You asked the Plan to pay for physician visit. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
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 physician visit was not filed until January 6, 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 a hospital physician visit provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided on December 2, 2019.You asked the Plan to waive the coinsurance for genetic testing. You say that you 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 genetic testing.You received genetic testing on December 2, 2019. The total allowed amount is $3,250.40 and 20% of that is $650.08.  You have been asked to pay the total coinsurance amount of $650.08 for genetic testing. Genetic testing 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 coinsurance for genetic testing provided on December 2, 2019.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the patient will benefit from acute rehab to optimize level of functioning prior to returning home. The Plan denied your request. The Plan says that the patient may be equally well served with skilled therapy services in Skilled Nursing Facility.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on March 5, 2021.

You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says you must
use the Plan's vision provider.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services when provided by a network optical provider.

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses
have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided
on March 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eleven (11) additional speech therapy visits.
You asked the Plan to pre-approve additional speech therapy visits. The Plan denied your request. The Plan says eleven (11) additional speech therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 eleven (11) additional speech therapy
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found in this case, you have previously been treated with speech therapy and should be independent with a home exercise program. The Health Plan has approved a single speech therapy session to determine if there is a need for further therapy sessions. Without an assessment of your current function and the proposed goals of therapy, the additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are not 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 eleven (11) additional speech therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eleven (11) additional speech therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 4, 2021.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you would like the plan to reconsider their denial.

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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. 

We find that CPT code 99204 is not supported in the medical record. Specifically, payment was already made for the same/similar procedure within the set time frame. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 28, 2021 by an out of network (OON) 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 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 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 the laboratory services provided on January 28, 2021 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of subcutaneous tissue provided on February 18, 2021.
You asked the Plan to pay for the wound care service. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the debridement of subcutaneous tissue provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 12, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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.

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and resin-based composite, or pay more for the comprehensive oral evaluation, and prophylaxis provided on August 8, 2018 by an OON provider.

You asked the Plan to pay for the complete series of intraoral x-rays, and resin-based composite, and to pay more for the comprehensive oral evaluation, and prophylaxis. You say that you believe these services should be covered. The Plan denied your request. The Plan says complete series of intraoral x-rays and resin-based composite are not covered under the Plan. The Plan also says that the cost share was applied correctly per your plan benefits, and cost-sharing is a contractual obligation of the Plan and cannot be waived.

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 complete series of intraoral x-rays
and resin-based composite are not among those covered under this benefit. The contract says that you also have
a $20 co-payment that you must pay, plus the difference between the billed amount and allowed amount for
services received OON. Therefore, we decided that the Plan does not have to pay for the complete series of
intraoral x-rays and resin-based composite, or pay more for the comprehensive oral evaluation, and prophylaxis
provided on August 8, 2018 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 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 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 August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a naturopath (99205) provided on January
27, 2021.
You asked the Plan to pay for an office visit with a naturopath. You say that this is a covered service. The Plan
denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have
to pay for an office visit with a naturopath (99205) provided on January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heel lift (L3310).
You asked the Plan to pre-approve a heel lift. You say that a heel lift is medically necessary. The Plan denied your request. The Plan says a heel lift is not a covered benefit under your contractual policy or by Medicare for your condition.
Medicare rules state that supportive devices for the feet (such as heel lifts) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although the heel lift may be appropriate for you, the Plan nor Medicare provides coverage of a heel lift for your condition. Therefore, we decided that the Plan does not have to pre-approve a heel lift (L3310).