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

We decided that the Plan does not have to pay for the central motor evoked potential study coded 95939, the short-latency somatosensory evoked potential studies coded 95927 and 95938, and the needle electromyography services coded 95861 and 95868 provided on July 16, 2020.
You asked the Plan to pay for the central motor evoked potential study, the short-latency somatosensory evoked potential studies, and the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 95939, 95927, 95938, 95861 and 95868 are not supported in the medical record. Specifically, the billed place of service for these services (place of service 15; mobile unit) is not supported. The documentation supports that the enrollee was an inpatient at the time services were provided. Based on this information, we decided that Medicare rules for coverage of the central motor evoked potential study, the Short-latency somatosensory evoked potential studies, and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the central motor evoked potential study coded 95939, the short-latency somatosensory evoked potential studies coded 95927 and 95938, and the needle electromyography services coded 95861 and 95868 provided on July 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 11, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that cardiovascular risk assessment testing was medically reasonable and necessary for the enrollee in this case. It has not been demonstrated that the testing in this case would impact the management and outcome of this enrollee. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth services provided by a participating provider on November 19, 2020.
You asked the Plan to waive the copayment for telehealth services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $15 copayment for physician/practitioner services. You have been asked to pay a $15 copayment for telehealth services. Telehealth services fall within the physician/practitioner services 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 telehealth services provided by a participating provider on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewings (D0274), and prophylaxis (D1110) provided by an out-of-network (OON) provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, bitewings, and prophylaxis. You say that you would like these services to be covered at the in-network rates. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), bitewings (D0274), and prophylaxis (D1110) provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152) provided on March 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
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 99152 is "Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older".
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use
of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the operative
report does not include documentation of the presence of an independent trained observer who assisted in
monitoring the patient during the procedure. Therefore, this service cannot be confirmed.
We looked at this coder's review, the file, and Medicare rules. 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 (CPT 99152) provided on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cologuard test (CPT code 81528).

You asked the Plan to pre-approve a Cologuard test. You say that blood was found in your stool with a fecal occult blood test. You state coverage for the Cologuard test is needed as soon as possible so that you can determine the cause of recent symptoms. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Cologuard test have not been met. Medicare and the health plan only cover the Cologuard test if all the rules are met. Medicare rules say a person must be 50 to 85 years old for this test to be covered. It is also not approved if you have a positive test for blood in the stool or bowel symptoms that may require other testing. You state blood was found in your stool with a fecal occult blood test. Therefore, this test is not covered. Therefore, we decided that the Plan does not have to pre-approve a Cologuard test (CPT code 81528).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided November 5, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says requirements for approval have not been met.
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 valid relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records provided do not discuss the ordering physician discussing with the enrollee the need for the lumbar-sacral orthosis. 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 the lumbar-sacral orthosis (L0650) provided November 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing for 4 or more teeth per quadrant (D4341), the scaling and root planing for 1 to 3 teeth per quadrant (D4342), the osseous surgery (D4260), the extraction (D7210), the anesthesia (D9243), and the comprehensive periodontal evaluation (D0180) provided from October 21, 2020, to November 6, 2020.
You asked the Plan to pay for the dental services. You say that the Dental Plan sent you an email with a list of in network dental providers. You say that you proceeded to make an appointment with this provider. You say that you feel you should be reimbursed for these services. The Plan denied your request. The Plan says the dentist in this case was a non-participating provider. The Plan also says that the claim was 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. Though the Plan offers a dental benefit in excess of Medicare coverage, dental service that you receive from a non-participating provider are not among those covered under this benefit. The record shows that the services
you received on October 21, 2020, were provided prior to receiving the email with the list of in network providers from the Plan, which was dated October 23, 2020. The record shows that a pre-treatment estimate was provided for the service you received on November 6, 2020, advising that the service would not be covered. Additionally, the Evidence of Coverage clearly states that If you choose to receive services from an out of network (non-participating) dentist, be sure to ask the dentist if they have opted out of Medicare. The Dental Plan is unable to make payment for any services received from a provider that has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the scaling and root planing for 4 or more teeth per quadrant (D4341), the scaling and root planing for 1 to 3 teeth per quadrant (D4342), the osseous surgery (D4260), the extraction (D7210), the anesthesia (D9243), and the comprehensive periodontal evaluation (D0180) provided from October 21, 2020, to November 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on November 4, 2020.
You asked the Plan to waive the copayment for emergency care. You say that the emergency room visit was due to COVID-19 and you thought all copayments were waived. 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 $90 copayment for emergency care. You received emergency care on November 4, 2020. Emergency care is not included in the COVID-19 copayment waiver. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Purewick catheters.
You asked the Plan to pre-approve these services. You say that the services were previously approved. The Plan denied your request. The Plan says the services are not covered.
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 pre-approve Purewick catheters.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), seat elevator (E2300), and foot plate pads (K0108).

You asked the Plan to pre-approve an expandable controller, seat elevator, and foot plate pads. You say that these items are medically necessary. The Plan denied your request. The Plan says these services cannot be covered.

The Plan must follow Medicare rules. The rules say that an expandable controller is covered when it is medically necessary to accommodate proportional input devices, non-proportional input devices, to operate 3 or more powered seating actuators, to operate a separate display/other electronic devices, or an attendant control. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.

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 expandable controller. Our reviewer says that the expandable controller is not medically reasonable and necessary. Our physician reviewer found that your function in the upper extremities of self-feeding and transfer ability supports that the patient can control any power options through their own individual switches.

In addition, the seat elevator and foot plate pads in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), seat elevator (E2300), and foot plate pads (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648), knee orthosis (L1833) and suspension sleeve (L2397).
You asked the Plan to pay for a lumbar-sacral orthosis, knee orthosis, and suspension sleeve. You say that the items provided were medically necessary. The Plan denied your request. The Plan says there was no established relationship between ordering physician and member.
The Plan follows Medicare rules. Medicare rules say that the orthoses are subject to the criteria listed 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 pay for a lumbar-sacral orthosis, knee orthosis, and suspension sleeve. Our reviewer says that the requested items were not medically reasonable and necessary. Our physician reviewer found the records do not show a direct physical examination, report of prior conservative efforts or prior relationship with the ordering physician. There was no other objective evidence of the diagnosis such as x-rays. Therefore, without sufficient support made for this request the lumbar-sacral orthosis (L0648), knee orthosis (L1833) and suspension sleeve (L2397) will each be considered 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 a lumbar-sacral orthosis, knee orthosis, and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648), knee orthosis (L1833) and suspension sleeve (L2397).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient care.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that this is not medically necessary.

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.

You were provided the inpatient care by a contract provider. The file does not show that the Plan provided notice that the inpatient care would not be covered. Under Medicare rules, this means the inpatient care is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the inpatient care.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance transportation provided on August 28, 2020.
You asked the Plan to pay for the air ambulance services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer says that the requested air ambulance services are not medically reasonable and necessary. Our physician reviewer found that the documentation did support that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the patient's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee.
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 air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance transportation provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that repeat MBBs are covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and has had two sets of diagnostic MBBs. One set provided 85 percent pain relief and the other 100 percent. The next step is radiofrequency ablation, not repeat MBBs. The requested MBBs are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat medial branch blocks (MBBs).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on September 23, 2020.
You asked the Plan to pay for Guardant360 testing. You say that this should be paid because this is the only provider for these services. 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. To report a CGP service, test providers should use CPT code 81479. We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported in the medical record. Specifically, the testing at issue is a CGP service and should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on September 23, 2020.