Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided February 9, 2021.  You asked the Plan to provide additional payment for the lower partial denture. You say that you were dissatisfied with the services provided and do not feel you should be responsible for any cost. The Plan denied your request. The Plan says the services provided have been 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. The Plan covers the lower partial denture with 70% coinsurance.  We looked at the file, and Medicare rules. In this case the Plan says they have contacted the dental provider who states that you have paid a total of $477.50 for your partial lower dentures. This means you have been asked to pay less than the correct amount ($962 allowed amount x 70% coinsurance = $673.40) based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided February 9, 2021.   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the emergency ambulance services (A0429 and A0425) provided on June 21, 2021.  You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration because the ambulance services were medically reasonable and necessary. The Plan denied your request. The Plan says that the member did not have a covered diagnosis for the rendered services.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 the emergency ambulance services. Our reviewer says that the review indicates that the enrollee was a then 37 yo female with a history of alcohol/opiate abuse who complained of abdominal pain x 4 days. Our physician reviewer found the member's presenting symptoms met prudent layperson criteria for emergency care.  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 emergency ambulance services have been met. Therefore, we decided that the Plan has to pay for the emergency ambulance services (A0429 and A0425) provided on June 21, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80053, 84443, 85025) provided on June 23, 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 out-of-network services were not pre-authorized.  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 services at issue in this appeal. 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 lab services (80053, 84443, 85025) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a cardiomyopathy risk panel (81407, 81479, 81405, 81406, 81286) provided on September 2, 2021.  

You asked the Plan to pay for a cardiomyopathy risk panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported by medical records.  

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.  

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a cardiomyopathy risk panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiomyopathy risk panel (81407, 81479, 81405, 81406, 81286) provided on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office services (CPT code(s): G0467 and 99213) provided on October 7, 2021, by an out-of-network provider.  

You asked the Plan to pay for the out-of-network services. You say that you went to this local clinic because you could not get into your clinic. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office services (CPT code(s): G0467 and 99213) provided on October 7, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) physical therapy (97110) provided April 23, 2021.  You asked the Plan to pay for the chiropractic services. You say that pursuant to your agreement, you do not believe you were allowed your contracted amount. The Plan denied your request. The Plan says these services are not covered when rendered 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 office visit (99203) physical therapy (97110) provided April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transport chair purchased on August 4, 2021.  You asked the Plan to pay for the transport chair. You say that the item is medically necessary. The Plan denied your request. The Plan says you obtained this item through a provider that is not enrolled in 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 transport chair purchased on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the telehealth office visit (99213) provided on September 1, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $30 copayment for each telehealth specialist visit.   You have been asked to pay a $30 copayment for the telehealth specialist visit provided. 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 telehealth office visit (99213) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88305, 88312, 88313) provided on June 15, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.  

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 laboratory services (88305, 88312, 88313) provided on June 15, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110-GP-CQ-KX) provided to the enrollee on December 16, 2020.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  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 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 service. Our reviewer found there is no documentation that the coding submitted by the provider (CPT code 97110-GP-CQ-KX) is the appropriate code for the services provided. CPT code G0157 appears to be the most appropriate code for the services provided.  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 service have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (CPT code 97110-GP-CQ-KX) provided to the enrollee on December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bed (A9270), sales tax (S9999), and mattress foam rubber (E0272), purchased on August 16, 2021.  You asked the Plan to pay for the bed and sales tax. You say that the items were medically necessary. The Plan denied your request. The Plan says there is no indication that any attempt was made to obtain prior authorization for the rendered services and that the provider is not an approved supplier by the plan.  Medicare rules say plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the bed (A9270), sales tax (S9999), and mattress foam rubber (E0272), purchased on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the three crowns (D2740 x3) and three core buildups, including any pins when required (D2950 x3) provided on August 23, 2021.  You asked the Plan to pay for the crowns and core buildups. You say that these services were provided due to knee surgery. You also say that you feel it should fall under your medical coverage. The Plan denied your request. The Plan says these 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. The file indicates that you do not pay for the additional optional dental benefits and our decision is made based on this information. Therefore, we decided that the Plan does not have to pay for the three crowns (D2740 x3) and three core buildups, including any pins when required (D2950 x3) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate (CPT code 00914) provided to the enrollee on May 12, 2021.  You asked the Plan to pay for the service. You say that this is a corrected claim that was done by your Certified Registered Nurse Anesthetist (CRNA) with modifier QX. You state that you will bill a separate claim for your doctor under a different tax identification (ID) and national provider identifier (NPI). You state the incorrect claim for the CRNA was billed in the amount of $823.20 and you request that clam to be dismissed. You state attached is the anesthesia record with the responsible staff listed and anesthesia times. The Plan denied your request. The Plan says the service is not covered as billed.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Medicare guidance says Appeal review performed on claim 1268186800KLC for CPT 00914QX on date of service (DOS) May 12, 2021. The result is the denial is upheld for the following reason, documentation submitted for appeal review does not support that the enrollee underwent two (2) separate anesthesia/operative sessions on the same DOS at different times, although the service used an Anesthesiologist and a CRNA, despite multiple requests for additional records they were unable to be obtained, this case is upheld for not meeting billing/coding criteria. The documented anesthesia time is 0730-0951=141 min for cystoscopy Holmium laser enucleation of the prostate. An anesthesia service with an equal or higher base unit value than {00914} was billed on May 12, 2021. Only the anesthesia code with the higher base unit value should be billed per operative session. Therefore, we decided that the Plan does not have to pay for anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate (CPT code 00914) provided to the enrollee on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the morphometric analysis services coded 88360 provided on May 27, 2021.  You asked the Plan to pay for the morphometric analysis 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.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services coded 88360 provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) telehealth visit provided on June 2, 2021.  You asked the Plan to waive the copayment for the PCP telehealth visit. You say that you were informed that you were approved for home care physical therapy with no copayment. 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 $10 copayment for each telehealth visit with your primary care physician (PCP).    You have been asked to pay a $10 copayment for the PCP telehealth visit. Please note that this charge is not related to your home physical therapy approval. The PCP telehealth visit falls 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 copayment for a primary care physician (PCP) telehealth visit provided on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on September 15, 2021, through September 18, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to pay anything. The Plan denied your request. The Plan says the cost share was applied correctly.  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 $360 copayment each day one through five for inpatient hospital care.      You have been asked to pay a $360 copayment each day one through five for the inpatient hospital care. This service falls within the inpatient hospital 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 the inpatient hospital care provided on September 15, 2021, through September 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided October 29, 2020.  You asked the Plan to pay for the acupuncture services. You say that please review. Attached are medical records for this date of service. The Plan denied your request. The Plan says the services were rendered by a non-covered provider type.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the acupuncture services were rendered by a licensed acupuncturist, not a physician. This provider is not supervised by a physician, PA, or NP/CNS. The provider is not a licensed physician per Medicare and EOC requirement. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. Your needs can be met safely and effectively at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.