Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0156) provided July 6, 2020.
You asked the Plan to pay for the home health services. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0156 is not supported in the medical record. Specifically, the provided records do not detail how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (G0156) provided July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blue metallic wheelchair shroud (K0108).
You asked the Plan to pre-approve the wheelchair shroud. You say that the item is medically necessary. The
Plan denied your request. The Plan says this item is not primarily medical in nature and is not covered.
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 pre-approve a blue metallic wheelchair shroud (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 6, 2020.
You asked the Plan to pay for the laboratory services. 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. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in a Residential Substance Abuse Treatment Facility setting POS 55. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82670, 84144, 82627, 84402, 84403, and 84443) provided on April 27, 2020.
You asked the Plan to pay for the laboratory services. 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 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (82670, 84144, 82627, 84402, 84403, and 84443) provided on April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that this equipment is medically necessary. The Plan denied your request. The Plan says there is no evidence the current device is not able to meet your medical needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a home oxygen concentrator. A home oxygen concentrator serves the same purpose as a portable oxygen concentrator. There is no evidence this equipment is not sufficient at this time. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided January 8, 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 documentation does not support the services 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.
We find that CPT code 80307 and G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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, G0483) provided January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 31, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures represented by code 77003
provided on February 4, 2021.
You asked the Plan to pay for code 77003. 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, we have confirmed that code 77003 has a bundled relationship with codes 61050, 61055, 62267, 62273, 62280, 62281, 62282, 62284, 64449, 64510, 64517, 64520, 64610, and 96450 and cannot be paid as billed. This code cannot be paid as a separate line item. Code 77003 is an add-on code and is eligible for payment only if it is reported with an appropriate primary procedure code performed by the same practitioner. The claim was not submitted with an appropriate primary procedure code. 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 fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures represented by code 77003 provided on February 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services represented by codes 93308, 93321, and 93325 provided on March 30, 2021.
You asked the Plan to pay for codes 93308, 93321, and 93325. 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, we have confirmed that codes 93308, 93321, and 93325 have a bundled relationship with code 33361 and cannot be paid as billed. These codes cannot be paid as a separate line item without a valid modifier. 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 echocardiography services represented by codes 93308, 93321, and 93325 provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar joint injection services provided on April 8, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the maximum frequency per day is one unit.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar joint injection services provided on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit provided on May 15, 2021.
You asked the Plan to reduce the copayment for the office visit. You say that you have had to pay a $15 copayment for urgent care in the past. You say you should only be charged a $10 copayment. 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 $15 copayment for each covered office visit to other providers for urgently needed services.
You have been asked to pay a $15 copayment for the office visit. The office visit falls within "Urgently needed services" benefit category. The record shows you were seen at an urgent care center by another provider. 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 reduce the copayment for the office visit provided on May 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149).
You asked the Plan to pre-approve a heavy-duty walker. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for beneficiaries who weight more than 300 pounds. We looked at the file and Medicare rules. In this case, the medical records provided confirm that your weight is less than 300 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker (E0149).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) and guided tissue regeneration - resorbable barrier, per site (D4266) provided April 30, 2021.
You asked the Plan to pay for the bone replacement graft and guided tissue regeneration. You say that the provider told you all services related to the extraction would be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 bone
replacement graft for ridge preservation - per site (D7953) and guided tissue regeneration - resorbable barrier, per site (D4266) provided April 30, 2021.
Your complaint about potentially being provided misinformation by the provider or the Plan 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were unable to get the authorization before the service was done. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the pain management services at issue in this appeal. The Plan did not pre-approve the services 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 the office visit provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services represented by code 99239 provided on October 29, 2020.
You asked the Plan to pay for code 99239. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99239.
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 99239 is Hospital discharge day management; more than 30 minutes.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray and adjunctive pre-diagnostic test provided on April 26, 2021.
You asked the Plan to pay for the additional intraoral x-ray and adjunctive pre-diagnostic test. You say that the dentist was off this day, so they gave you another dentist. You say that the office did not tell you the dentist was not in-network and you got stuck with the total bill. The Plan denied your request. The Plan says the claim has been reprocessed and the covered services were allowed at the in-network level of benefits. The additional intraoral x-ray and adjunctive pre-diagnostic test remain denied as not covered benefits.
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, you also have a maximum benefit of one intraoral x-ray is covered per calendar year. The Plan paid for one intraoral x-ray provided on April 26, 2021, which exhausted your benefit. The adjunctive pre-diagnostic test is also denied as it is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray and adjunctive pre-diagnostic test provided on April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 9, 2021.
You asked the Plan to pay for the laboratory services. 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 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies provided on February 18, 2021.
You asked the Plan to pay for additional supplies, materials, and clinical staff time over and above those
usually included in an office visit or other non-facility service(s), when performed during a Public Health
Emergency, as defined by law, due to respiratory-transmitted infectious disease (99072). You say that you would like the Plan to reconsider payment. The Plan denied your request. The Plan says this code is always bundled into payment for other services and no separate payment is made per Medicare.
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 Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease (99072) has a Status Code of B, bundled into payment for other services, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies provided on February 18, 2021.
Please note, the Plan is handling the other services of your appeal separately.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound repair surgery provided on April 22, 2021.
You asked the Plan to waive the copayment for the wound repair surgery. You say that you have had this surgery before and have never paid a copayment. 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 $350 copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $350 copayment for the wound repair surgery.
You have been asked to pay a $208.35 copayment for the wound repair surgery. The wound repair surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 wound repair surgery provided on April 22, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve total shoulder arthroplasty.
You asked the Plan to pre-approve total shoulder arthroplasty. You say that you live in pain every day. You also feel this surgery will be best for you. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 total shoulder arthroplasty. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you are being treated for idiopathic aseptic necrosis of unspecified shoulder. You presented with an extreme amount of pain in the left shoulder and has very little mobility. Exam reveals active forward flexion about 120. External rotation 30, after that you have significant posterior pain and a locking type sensation in your shoulder. Internal rotation is to the greater trochanter. X-rays are noted from this date to suggest collapse of that avascular necrosis fragment; undermining of the bone below the subchondral bone as well. You are noted to have persistent and ongoing significant pain in the left shoulder with decreased ability to function. The treating provider addressed the concern for infection and noted antibiotic beads could be utilized during the procedure. Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities has been documented. Therefore, you meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total shoulder arthroplasty have been met. Therefore, we decided that the Plan has to pre-approve total shoulder arthroplasty.