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

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and panoramic x-ray (D0330)
provided on March 24, 2021.

You asked the Plan to pay for the bitewing x-rays and panoramic x-ray. 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. Therefore, we decided that the Plan does not have to pay for the
bitewing x-rays (D0274) and panoramic x-ray (D0330) provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 83516, 83520, 86332, 86353, 86356, 88184, 88185, 88230, 88240, 88241, 88346, and 88350 provided on March 3, 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 are not payable as billed.

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 laboratory testing 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 coded 83516, 83520, 86332, 86353, 86356, 88184, 88185, 88230, 88240, 88241, 88346, and 88350 provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed and an over-the-bed table.
You asked the Plan to pre-approve the requested items. You say that you have back pain from spine misalignment. The Plan denied your request. The Plan says the requested items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. The rules say that for equipment to be covered, it must primarily serve a medical purpose. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. The requested table 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.
Based on this information, we decided the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and an over-the-bed table.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eleven (11) home health PT visits (CPT code G0151 X 11), for the enrollee.

You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan denied your request. The Plan says the medical record does not document a clearly evident need for the services of a skilled physical therapist. The Plan states the enrollee has already been educated on a home exercise program. The Plan states there is no documentation of an active or acute on chronic condition that would necessitate a new program.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented home health (HH) skilled therapy needs. The enrollee is functioning at a level commiserate with a lower level of care (i.e. outpatient therapy, HEP). As such, the requested, ongoing, HH PT services are not medically necessary or reasonable.

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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve eleven (11) home health PT visits (CPT code G0151 X 11), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas neoGen-Series therapy (electrical cell stimulation) (codes 97032, 96372, 97112, J3415, J3411, J1955, J3420, and J3490) and Vasopneumatic device therapy (code 97016) provided on August 20, 2020.

You asked the Plan to pay for the Sanexas neoGen-Series therapy and Vasopneumatic device therapy. You say that the enrollee has tried other modalities and treatments to help relieve the pain that had either failed, had side effects, or has not alleviated the pain. You also say that these services were deemed medically necessary by the attending physicians. The Plan denied your request. The Plan says these services are considered to be experimental or investigational and are not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a NP or PA only when that NP/PA may perform physical therapy services under State law. Medicare rules also say that claims for compounded drugs shall be submitted using a compounded drug, NOC code. 

During the review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Virginia. Also, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of the Sanexas neoGen-Series therapy and Vasopneumatic device therapy have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas neoGen-Series therapy (electrical cell stimulation) (codes 97032, 96372, 97112, J3415, J3411, J1955, J3420, and J3490) and Vasopneumatic device therapy (code 97016) provided on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair carrier.

You asked the Plan to pre-approve a wheelchair carrier. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is one of convenience and is not primarily medical in nature.

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 wheelchair carrier.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87496, 87498, 87798, 87486, 87541, 87581, 87640) provided November 4, 2020.

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 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 87496, 87498, 87798, 87486, 87541, 87581, & 87640 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 (13, 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 (87496, 87498, 87798, 87486, 87541, 87581, 87640) provided November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 25,
2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services are not payable 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 G0483 is drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug
testing coded G0483 provided on November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. The Plan denied your request. The Plan says this is a non-covered item.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided October 6, 2020 to October 11, 2020.
You asked the Plan to pay for the inpatient hospital care. You say that DRG 091 was correctly billed. The Plan denied your request. The Plan says DRG 092 is more appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 091. 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 inpatient hospital care. Our reviewer says that DRG 091 is not supported by the records. Our physician reviewer found the determination to remove secondary diagnosis code I63.9 (Cerebral infarction, unspecified) is appropriate. Documentation supported an admission for a stroke during a cardiac catheterization procedure. The hospital reported I97.810 (Intraoperative cerebrovascular infarction during cardiac surgery) and I63.9 (Cerebral infarction, unspecified). Code I97.810 is fully describing the patient's condition of intraoperative cerebrovascular infarction. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided October 6, 2020 to October 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on December 24, 2020.

You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken and the code should be reprocessed for prompt payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

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 99072 is 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.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on December 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not covered.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on April 22,
2021.
You asked the Plan to waive the copayment for emergency care. You say that the copayment should be waived
because you got sick after receiving the Moderna vaccine. The Plan denied your request. The Plan says the
claims were processed correctly, and you are being charged the correct 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
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 emergency care provided on
April 22, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).

You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that this requested imaging service is medically necessary and reasonable. The Plan denied your request. The Plan says that the criteria for a CT scan have not been met.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a CT scan of the abdomen and pelvis. Our reviewer says that the requested imaging service is medically necessary and reasonable for the enrollee. Our physician reviewer found the patient has a history of T3N0M0 adenocarcinoma of the esophagus treated with upfront surgery (due to large hiatal hernia) on October 23, 2019, and adjuvant chemotherapy without radiotherapy. Notably, this patient did not undergo radiation due to the large hiatal hernia which precluded safe delivery of radiation. Thus, he does not fall with any National Comprehensive Cancer Network follow-up guidelines and is likely at higher risk of recurrence for not receiving radiation. Therefore, another CT scan 6 months from the patient's last scan would be within accepted standards 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 a CT scan of the abdomen and pelvis have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract surgery on the left eye
provided on July 1, 2021.

You asked the Plan to waive the coinsurance for the cataract surgery on the left eye. You say that you would
like the same coverage which you received for a standard cataract lens to be applied to the upgraded cataract
lens on July 1, 2021. 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 30%
coinsurance per out-of-network (POS) visit.

You have been asked to pay $311.79 which is 30% of the allowed amount for the cataract surgery on the left
eye. The allowed amount is $1,039.30. ($1,039.30 x 30% = $311.79). The cataract surgery on the left eye falls
within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers" benefit category. The record shows the cataract surgery was provided at an out-of-network
ambulatory surgical center.

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 cataract surgery on the left eye provided on July 1,
2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on April 12, 2021.

You asked the Plan to pay for the ground mileage and non-emergency ambulance transport. You say that one transport was provided to this enrollee and was medically necessary. The Plan denied your request. The Plan says the enrollee's claims history indicates they were in an inpatient hospital status on this date of service. The Plan also says that the referring claim shows an admit date of April 8, 2021, and a discharge date of April 14, 2021.

The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital, it may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have not been met. Specifically, the record shows that the enrollee was admitted as inpatient to the origin location provider. The record also shows that the enrollee was transported to another provider while maintaining inpatient status with the original provider. This means that the ambulance service is covered as an inpatient hospital service and is not separately billable. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on April 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Solifenacin tablets.
You asked the Plan to pre-approve the Solifenacin tablets. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Solifenacin tablets.
Benefits for the Solifenacin tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.