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

We decided that the Plan does not have to pay for a Prostate Cancer screening (G0103) provided September 14,
2021.
You asked the Plan to pay for the Prostate Cancer screening. You say that this service was medically necessary.
The Plan denied your request. The Plan says this service is covered once per year. The number of allowed tests
has been exceeded.
The Plan must follow Medicare rules. Medicare rules say that Screening prostate specific antigen tests are
covered at a frequency of once every 12 months.
We looked at the file and Medicare rules. This service was previously covered on March 11, 2021. Based on
this information, we decided that Medicare rules for coverage of the Prostate Cancer screening have not been
met. Therefore, we decided that the Plan does not have to pay for a Prostate Cancer screening (G0103)
provided September 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76705) provided September 23, 2021.  You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and 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 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (76705) provided September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921), partial upper denture
(D5213), partial lower denture (D5214), removal of residual tooth roots (D7250), and unspecified preventive
service (D1999) provided on August 26, 2021.

You asked the Plan to pay for the dental services. You say that when you signed up for the plan in 2018 you
were advised that dentures were covered. You say that this is the reason you signed up for the plan. You also
say that the plan should honor what they told you. The Plan denied your request. The Plan says the services you
received are not listed as covered services.

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 gingival irrigation, partial dentures,
removal of residual tooth roots, and unspecified preventive service are not among those covered under this
benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921), partial
upper denture (D5213), partial lower denture (D5214), removal of residual tooth roots (D7250), and
unspecified preventive service (D1999) provided on August 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (procedure code 97010) provided to the enrollee on June 28, 2021.  You asked the Plan to pay for the services. You say that the claim was processed as out-of-network which resulted in incorrect payment. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 97010 is "Application of a modality to 1 or more areas; hot or cold packs."  We find that CPT code 97010 is not supported in the medical record. Specifically, this code has a status indicator of "B" which indicates that it is always bundled into payment for other services and can never be paid separately. 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 physical therapy services (procedure code 97010) provided to the enrollee on June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve male breast reduction surgery.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover surgery for enlarged breasts (gynecomastia) when it is caused by medication.

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 pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available medical records support that the enrollee has a pathological cause for gynecomastia (drug-induced). In addition, it has not been demonstrated that the enrollee's gynecomastia persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia. The documentation does not support that the enrollee has pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living, that the enrollee has clinical symptoms that are refractory to a trial of analgesics or anti-inflammatory agents, and that the enrollee has significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve male breast reduction surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for endodontic services provided on August 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for endodontic services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says services must be provided by a participating provider. The Plan says that the rendering dentist is out-of-network.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for endodontic services provided on August 13, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genomic testing (procedure code 81455) provided to the enrollee on December 10, 2020.  You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary and screening testing.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found these services are unlikely to impact therapeutic decision-making in the clinical management of the enrollee. The review has determined that the services at issue in this case are not medically reasonable or 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for genomic testing (procedure code 81455) provided to the enrollee on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided September 6, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. No medical records were provided to support the services billed. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided September 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 0.4mg Tamsulosin capsules.

You asked the Plan to pre-approve the Tamsulosin capsules. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not covered under Medicare Part B.

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 the 0.4mg Tamsulosin capsules.

Benefits for the Tamsulosin capsules may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99337) provided on July 22, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a domiciliary or rest home visit. You say that the patient was in a nursing home setting at the time services were rendered and could not choose an in-network specialist since no other provider was allowed into the facility during the pandemic. You also say that the provider has no prior knowledge of which patients he will be required to see until he arrives at the facility and receives a list of patients who require care. The Plan denied your request. The Plan says this claim was denied for failure to obtain the required prior authorization and it was determined the services were not urgent or emergent in nature. The Plan also says that an authorization was not obtained prior to the services being rendered.

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 a domiciliary or rest home visit (99337) provided on July 22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on September 9, 2021.  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 CPT code 99153 is not separately payable when performed by a physician in a facility setting.  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 99153 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service)."  We asked our coder 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 services at issue in this case were not supported by the medical records. Our reviewer found the medical records and billing records indicate the service 99153 was performed in Place of Service 21. CPT 99153 per the National Physician Fee Schedule Relative Value File, July release states 99153 may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department, therefore 99153 is not eligible for reimbursement consideration.    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 moderate sedation services (procedure code 99153) provided to the enrollee on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a standard power wheelchair.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the chair is not irreparably damaged.  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 pre-approve the wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that you meet Medicare criteria for the requested new power wheelchair. Provided records do not document that your present power wheelchair (which is less than 5 years old) has been lost, stolen or is irreparably damaged.   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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided by Central Minnesota Foot and Ankle on September 27, 2021.

You asked the Plan to pay for foot orthotics. You say that you are disables and this is a financial hardship. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) 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 orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided by Central Minnesota Foot and Ankle on September 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychological or neuropsychological test administration (96136) provided on July 26, 2021.  You asked the Plan to pay for psychological or neuropsychological test administration. You say that this is a payable code. The Plan denied your request. The Plan says this cannot be paid 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 CPT Code Manual definition of code 96136 is psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes.  We find that CPT code 96136 is not supported in the medical record. Specifically, the time spent on this service is not documented. Based on this information, we decided that Medicare rules for coverage of psychological or neuropsychological test administration have not been met. Therefore, we decided that the Plan does not have to pay for psychological or neuropsychological test administration (96136) provided on July 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) received on September 16,
2021.

You asked the Plan to pay for the drugs. You say that the denial of payment should be reconsidered. The Plan
denied your request. The Plan says this is not a covered benefit.

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 pay for self-administered drugs (A9270)
received on September 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 19, 2021.  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 an appropriate modifier was not 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ophthalmology visit, eye scanning test, and eye ultrasound provided on September 16, 2021.

You asked the Plan to waive the copayments for the ophthalmology visit and eye tests. You say that you have never been charged for these tests in the past. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $50 copayment for services for the diagnosis and treatment of diseases and injuries of the eye. 

Your contract with the Plan also clearly says that you must pay a $25 copayment for outpatient diagnostic procedures and tests.

You have been asked to pay a $50 copayment for the ophthalmology visit. The ophthalmology visit falls within the Vision Care benefit category. You have also been asked to pay a $25 copayment for the eye scanning test, and $11.86, which is less than the $25 copayment, for the eye ultrasound. The scanning test and eye ultrasound fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total for the visit is $86.86. 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 copayments for an ophthalmology visit, eye scanning test, and eye ultrasound provided on September 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services received on February 25, 2021.
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 this is an unbundled service.
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 12002 is a column II code to column I code 25560. This claim has
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing
criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services
received on February 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from August 18, 2021, to September 16, 2021.  You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says there was no daily skilled nursing or therapist need.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 skilled nursing facility (SNF) services provided to the enrollee from August 18, 2021, to September 16, 2021.