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

 We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on August 12, 2021.  

You asked the Plan to pay for the SelectMDx testing (81479). 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 must follow Medicare rules. Medicare rules say that providers must report services correctly.          

We looked at the file and Medicare rules. Medicare specifically excludes coverage of code 81479 when used for SelectMDx testing. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 17, 2021.
You asked the Plan to pay for the limited oral exam. You say that this service was necessary for a health issue. The Plan denied your request. The Plan says you have exceeded the frequency limit 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. The Plan covers the limited oral exam once per plan year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on May 24, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided August 17, 2021.
Your complaint about the Plan placing frequency limits on certain services in the Plan contract is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on July 28, 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 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 (procedure code 70450) provided to the enrollee on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat cervical facet joint radiofrequency ablation (RFA) procedure for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is not supported.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the guidelines require diagnostic medial branch blocks, because it has been more than two years since the last radiofrequency ablation procedure.

Therefore, the requested RFA at this point is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat cervical facet joint radiofrequency ablation (RFA) procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-covered service (99213) provided on June 17, 2021.  

You asked the Plan to pay for code 99213. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says code 99213 is not payable when billed by a chiropractor.  

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered service (99213) provided on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70544.

You asked the Plan to pay for procedure code 70544. You say that the patients had multiple exams on this date of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for another code billed on the same date and no modifier was appended.

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 procedure code 70544 is a column II code to column I code 70553.

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 procedure code 70544.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided on July 28, 2021, to August 19, 2021.

You asked the Plan to waive the copayments for the office visits. You say that you are appealing these copayments. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered physician services.

You have been asked to pay a $10 copayment for each of the office visits. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the office visits provided on July 28, 2021, to August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection (J0897) provided on June 7, 2021.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you were not aware that you would be charged a coinsurance for this Medicare Part B prescription drug. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total cost share of $241.08 for the Prolia injection ($1205.40 Medicare-allowed amount x 20% coinsurance). The Prolia injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Prolia injection (J0897) provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of lateral exostosis (D7471) and removal of torus mandibularis (D7473) provided on January 4, 2021.

You asked the Plan to pay for the removal of lateral exostosis and removals of torus mandibularis. You say that you were not aware that these procedures were not covered. The Plan denied your request. The Plan says these services are not covered under the Plan.

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 removal of lateral exostosis (D7471) and removal of torus mandibularis (D7473) provided on January 4, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services provided to the enrollee on July 27, 2021.

You asked the Plan to pay for the services. You say that the participating doctor sent the specimen for processing. The Plan denied your request. The Plan says that the services were not urgent, emergent, or approved in advance.

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. Additionally, 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. 

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 has not substantiated the denial. The plan has not provided any information on who ordered this testing. The laboratory claims the provider is participating, which would mean these services are covered based on plan-directed care. The file does not show that the plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means that the services would be considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on July 27, 2021.

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: Testing
Decision: Favorable

We decided that the Plan has to pay for procedure code 93971-LT-XS billed for date of service April 29, 2021.

You asked the Plan to pay for procedure code 93971-LT-XS. You say that this code was billed with the appropriate XS modifier to warrant separate payment. The Plan denied your request. The Plan says that it incorrectly categorized your appeal as a payment dispute. Since the Plan missed their deadline, they automatically forwarded the case to us for review.

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. must pay for procedure code 93971-LT-XS billed for date of service April 29, 2021. The Plan has made no argument that modifier XS was appended inappropriately. The Plan has provided no argument that this code shouldn't be separately payable as billed. Therefore, we decided that the Plan has to pay for procedure code 93971-LT-XS billed for date of service April 29, 2021.

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 transportation of portable x-ray equipment and personnel (R0070) provided on July 6, 2021.

You asked the Plan to pay for code R0070. 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. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code R0070 is Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. 

We find that CPT code R0070 is not supported in the medical record. The provider reported transportation of portable radiology equipment but did not report setup codes, which does not follow industry standard coding rules. Transportation services are not reimbursable without the reporting of setup services. Diagnostic x-ray setup and transportation services were not performed by the portable x-ray provider. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel (R0070) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4267) and bone replacement graft for ridge preservation (D7953).

You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that you are currently not able to get your teeth due to the damage in your mouth. You also say that you need these services provided in order to eat. The Plan denied your request. The Plan says these services are not covered under your plan.

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 pre-approve a guided tissue regeneration (D4267) and bone replacement graft for ridge preservation (D7953).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (procedure code 99285) provided to the enrollee on June 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 the diagnosis codes submitted with the claim should not be reported together.

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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."

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 diagnosis codes submitted to the health plan for service 99285 were K59.00 - (Constipation, unspecified) and K56.41 - (Fecal impaction). K59.00 notes an "Excludes K56.41" and K56.41 notes "Excludes K59.0." In the Official Guidelines for Coding and Reporting, Excludes 1 Notes indicate these codes should not be reported together. As a result, 99285 has been billed with missing/incomplete/or invalid diagnosis codes and is not eligible for reimbursement. 

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 emergency services (procedure code 99285) provided to the enrollee on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on July 13, 2021.

You asked the Plan to pay for the periodic oral evaluation. You say that two periodic dental exams are covered each year. You also say that the services provided on April 1, 2021 is not correct because it was not an exam, but a repair. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits, and the service provided on April 1, 2021 was billed as a periodic oral evaluation (D0120).

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, periodic oral exams (D0120) are limited to two procedure codes per calendar year. The record shows that you received periodic oral evaluations (D0120) on January 6, 2021, and April 1, 2021 and your periodic oral exams (D0120) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the snore guard and warranty provided on October 31, 2019.

You asked the Plan to pay for the snore guard and warranty. You say that you were under the impression the mouthpiece would be covered at 75%. You say that the mouthpiece is to treat sleep apnea which is a medical condition and should be covered as medical. The Plan denied your request. The Plan says the services are not covered.

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 snore guard and warranty provided on October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Truxima for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Truxima is an biosimilar form of Rituximab (which has been approved), which would essentially be a duplicate therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the provider has made a request for Rituximab and Truxima. The request for Rituximab has been approved. The requested Truxima would essentially be duplicate therapy. It is similar to the medicine Rituximab that was requested and approved. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Truxima for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on June 8, 2021.

You asked the Plan to pay for the services. You say that the explanation of benefits did not give adequate information to establish the accuracy of the decision. The Plan denied your request. The Plan says these items are not a covered benefit.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (E0675) to treat peripheral artery disease is not eligible for reimbursement. 

The requested device (E0675) and accessory (E0673) are statutorily not covered by Medicare. 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 a pneumatic compression device (E0673, E0675) provided to the enrollee on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 16, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should not have to pay a copayment for a follow-up after surgery. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each covered visit or consultation in an outpatient location with a specialist.

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up to a surgical procedure.

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 the specialist office visit provided on July 16, 2021.