Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy evaluation provided by an occupational therapy assistant on February 4, 2020.

You asked the Plan to pay for the occupational therapy evaluation. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy evaluation have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation provided by an occupational therapy assistant on February 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incomplete root canal (D3332 provided on May 3, 2021.
You asked the Plan to pay for the incomplete root canal. You say that the enrollee came in for a root canal. You say that the procedure was not able to be completed. You also say that the enrollee was referred to an endodontist. The Plan denied your request. The Plan says incomplete root canal is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the incomplete root canal is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the incomplete root canal (D3332 provided on May 3, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on September 24, 2020.
You asked the Plan to pay for the physical therapy services. You say that there is no contractual agreement in place that indicates the codes billed are included in the dialysis rate. You say that the codes needs to be reprocessed for payment due. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 27, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the treating physician did not order this testing.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided do not contain documentation of the ordering physician's intent that the tests be performed.

Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Cods 80324, 80345, 80346, 80349, 80353, 80358, 80361 and 80365, are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes.
Medicare uses another code for reporting of, and payment for, these services. 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 provided on July 21, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker purchased on June 30, 2021.
You asked the Plan to pay for the walker. You say that the item should be covered. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate with Medicare, you will be responsible for the full cost of the services you received.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the walker purchased on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures (D5110 and D5120), provided on September 14, 2021.

You asked the Plan to pay for the dentures. You say that the service was medically necessary. The Plan denied your request. The Plan says you have exhausted your plan benefit for this 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 dentures (D5110 and D5120), provided on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power operated vehicle (POV) (K0800) and sales tax
(S9999), provided on July 6, 2021.
You asked the Plan to pay for the POV and sales tax. You say that you should be reimbursed. The Plan denied
your request. The Plan says you received your durable medical equipment from a provider who is not certified
with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the power operated vehicle (POV)
(K0800) and sales tax (S9999), provided on July 6, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain
(70450) provided on July 15, 2021.

You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based
on the medical documentation submitted. The Plan denied your request. The Plan says an appropriate modifier
was not billed with this service as required by Medicare rules.

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 the computed tomography (CT) scan of the head or brain (70450)
provided on July 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on January 15, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance service was not medically necessary. Our physician reviewer found the enrollee is a 73-year-old male with dementia and cerebrovascular accident (CVA) who was transported via ambulance from a SNF to a hospital to have a suprapubic catheter inserted. It was reported that he had weakness. He received no treatment during transport. The documentation does not support that other means of transport such as a stretcher van were contraindicated for this enrollee. The documentation does not support that the enrollee needed expertise, services, and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for the enrollee. A stretcher van would have been more appropriate.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on January 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93976) provided on July 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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 93976
is a column II code to column I code 76856. 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 the services (93976) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. 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 laboratory services rendered on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81314, 81405, 81211, 88360, 81170, 81479, 81202, 81210, 81272, 81403, 81235, 81400, 81404, 81245, 81270, 81275, 81276, 81310, 81311, 88360, 88377, 88381, 88374) provided on April 7, 2016.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
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 record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81314, 81405, 81211, 88360, 81170, 81479, 81202, 81210, 81272, 81403, 81235, 81400, 81404, 81245, 81270, 81275, 81276, 81310, 81311, 88360, 88377, 88381, 88374) provided on April 7, 2016.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the reclining seat lift chair (A9270), purchased on May 27, 2021.

You asked the Plan to pay for the reclining seat lift chair. You say that the item should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 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 pay for the reclining seat lift chair (A9270), purchased on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on May 26, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical radiographic images (x-ray) (D0220), limited oral evaluation (D0140), and preventative procedure (D1999), provided on November 13, 2021, to December 18, 2021.
You asked the Plan to pay for the periacipal x-ray, oral evaluation and procedure. You say that the services should be covered. The Plan denied your request. The Plan says you received care from an out-of-network provider.
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 periapical radiographic images (x-ray) (D0220), limited oral evaluation (D0140), and preventative procedure (D1999), provided on November 13, 2021, to December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 9, 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 the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 23, 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided March 5, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed frequency.
The Plan must follow Medicare rules. Medicare rules say that Medicare will consider presumptive drug testing in excess of 12 per Calendar year not reasonable and necessary. We looked at the file and Medicare rules. The billed drug testing exceeds the frequency allowance. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307) provided March 5, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing provided to the enrollee on May 5, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says this is not a Medicare benefit for the diagnosis listed.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is not covered based on the
current literature.
Medicare does not consider the denied testing to be medically reasonable or necessary. 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 CxBladder testing provided to the enrollee on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81240, 81241, 81291, and 81335 provided on June 28, 2021.

You asked the Plan to pay for the laboratory 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 supported by the documentation.

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 81240, 81241, 81291, and 81335 is not supported in the medical record. Specifically, the documentation shows that the enrollee had molecular pharmacogenetic testing on June 28, 2021. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel consists of a single procedural service, so one code must be submitted for the panel.

Review of the file shows that one code was not submitted for the panel provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81240, 81241, 81291, and 81335 provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intermittent limb compression device.

You asked the Plan to pre-approve the intermittent limb compression device. You say that you would like reconsideration because the requested equipment is Medicare covered benefit. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested compression device.

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

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 intermittent limb compression device. Our reviewer says that the elements of the coverage criteria have not been met. Our physician reviewer found the record indicates that the enrollee has chronic venous insufficiency and lymphedema that does not extend to the 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 intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve the intermittent limb compression device.