Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services described by current procedural terminology (CPT) code 77049 provided on October 19, 2020.

You asked the Plan to pay for CPT code 77049. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. CPT code 77049 has a status indicator of "B" and is not recognized by OPPS when submitted on an outpatient hospital Part B bill type 13X. Therefore, we decided that the Plan does not have to pay for the outpatient services described by current procedural terminology (CPT) code 77049 provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an OON provider.
You asked the Plan to pre-approve podiatry services. You say that you would like to continue to see this
provider. The Plan denied your request. The Plan says you have been approved for four out-of-network visits to
allow you to transition to an in-network provider.
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
podiatry services to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #22.

You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service exceeds the benefit allowance of once every 60 months.

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, core buildup, including any pins when required (D2950) is limited to once per 60 months per tooth. The record shows that the enrollee received a core buildup (D2950) on tooth #22 on April 16, 2019 and the enrollee's core buildup, including any pins when required (D2950) benefit for tooth #22 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) for tooth #22.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a seat frame width 20/21/22/23 for power wheelchair.
You asked the Plan to pre-approve a seat frame width 20/21/22/23 for power wheelchair. You say that you
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the nonstandard
seat frame width, 20-23 inches, represented by code E2340, is not covered as code E2340 is incorrect
and not valid. The Plan says that they will approve the requested item if the correct code is submitted.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan's only denial rationale for the requested seat frame width is the nonstandard
seat frame width, 20-23 inches being represented by code E2340 as being an invalid code. The Plan
says that they will approve the requested item if the correct code is submitted. However, Medicare says this
code is only invalid if submitted on a claim for payment. As this is a prior authorization request, the Plan's
reasoning for denial based on a CPT code is not valid. This is not a claim submission denial, as there is no
claim. Therefore, we decided that the Plan has to pre-approve a seat frame width 20/21/22/23 for power
wheelchair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and the emergency transport provided on November 16, 2019.

You asked the Plan to pay for the transportation services. You say that the enrollee was removed from hospice prior to the ambulance transport. 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 member'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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and the emergency transport provided on November 16, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and psychotherapy provided by an out-of-network provider on January 4, 2021.

You asked the Plan to pay for the office visit and psychotherapy. You say that the doctor deemed it medically necessary to see the patient. You say that even though authorization wasn't obtained the charge should be reconsidered.The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 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 office visit and psychotherapy provided by an out-of-network provider on January 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that the medical records provided should
support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee does
not meet the criteria for the requested service.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the above-described criteria.
We reviewed the file and the Medicare rules. We find that Lung cancer screening with CT is only supported for
patients over the age of 50 with a 30-pack year or more of smoking. There was no documentation provided to
show the enrollee's smoking history with regards to packs per years. Multiple attempts were made to contact
the provider's office to obtain this information with no success. Therefore, we decided that the Plan does not
have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet therapy cabinet (E0694).
You asked the Plan to pre-approve an ultraviolet therapy cabinet. You say that the requested item is medically
appropriate and very necessary for the enrollee to continue a daily functional lifestyle. The Plan denied your
request. The Plan says rules for an ultraviolet therapy cabinet have not been met.
The Plan must follow Medicare rules. Medicare rules say that ultraviolet cabinets are covered for selected
patients with generalized intractable psoriasis.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an ultraviolet therapy cabinet have not been met. Specifically, the provided medical records
indicate the requested item has been prescribed for atopic dermatitis, not intractable psoriasis. Therefore, we
decided that the Plan does not have to pre-approve an ultraviolet therapy cabinet (E0694).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy (OT) services performed in home health setting (G0152).
You asked the Plan to pre-approve OT therapy home health services. You say that this service is medically necessary. The Plan denied your request. The Plan says clinical notes do not support that the member's functional level requires the skill of an OT therapist.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 OT therapy home health services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found in this case; the documentation does not support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She should be independent with a home exercise program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OT therapy home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve occupational therapy (OT) services performed in home health setting (G0152).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on October 2, 2020.

You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with an incorrect POS.

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 testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on October 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the HHA or certified nurse assistant provided from August 31, 2020, to December 9, 2020.

You asked the Plan to pay for the HHA or certified nurse assistant. You say that you believe these services should be covered. The Plan denied your request. The Plan says you received home health aide services from a provider who is not certified for Medicare.

The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA or certified nurse assistant have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the HHA or certified nurse assistant provided from August 31, 2020, to December 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 11, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient admission provided from October 26, 2020, to October 29, 2020.
You asked the Plan to waive the deductible for the inpatient admission. You say that your deductible should have already met. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 there is a $300 deductible per calendar year for covered services received in a general acute care hospital. You will not pay more than $300 for inpatient hospital covered services in a calendar year. The inpatient admission you asked the Plan to waive the deductible for falls within the "Inpatient care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible per calendar year for covered services received in a general acute care hospital. You will not pay more than $300 for inpatient hospital covered services in a calendar year. This cost sharing is a contractual obligation that had not been met at the time the inpatient admission was received on October 26, 2020 to October 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the inpatient admission provided from October 26, 2020, to October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit and wound debridement provided by an out-of-network provider on November 11, 2020.
You asked the Plan to pay for the nursing facility visit and wound debridement. You say that the patient had no control over which physician would be assigned so the provider should be considered in-network. You say that wound care was provided to avoid delay in care and the claim should be considered for payment. The Plan denied your request. The Plan says services should be received from network providers.
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 nursing facility visit and wound debridement provided by an out-of-network provider on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on September 10, 2020.

You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you disagree agree with the increase in charges because you always paid a lower amount in the past. 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 $125 copayment for ultrasounds. 

You have been asked to pay a $125 copayment for an ultrasound of the heart. An ultrasound of the heart 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 of the heart provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) received December 15, 2020.

You asked the Plan to pay for the resin-based composite - one surface, posterior (D2391). You say that the requested procedure should be paid for by the Plan. The Plan denied your request. The Plan says you did not have coverage for this procedure on this date of 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 for the resin-based composite - one surface, posterior (D2391) received December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance (E0673) provided November 17, 2020.
You asked the Plan to pay for the pneumatic compression device. You say that the medical records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
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 is not supported in the medical record. Specifically, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance (E0673) provided November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services rendered on June 17, 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 procedure codes 78812, 74176, 70490, and 71250 are 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 78812 is positron emission tomography (PET) imaging; skull base to mid-thigh. The definition of code 74176 is computed tomography, abdomen and pelvis; without contrast material. The definition of code 70490 is computed tomography, soft tissue neck; without contrast material. The definition of code 71250 is computed tomography, soft tissue neck; without contrast material. We find that CPT codes 78812, 74176, 70490, and 71250 not supported in the medical record. Specifically, there is no documentation of PET imaging from skull base to mid-thigh for the billed date of service to support code 78812. Codes 74176, 70490, and 71250 are component codes for 78812 and given that 78812 is not supported, the component codes are also not supported. 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 imaging services rendered on June 17, 2020.