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

 We decided that the Plan does not have to pay for radiology services (93923) provided July 21, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed are not supported in the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that multiple units of CPT code 93923 are not supported in the medical record. The medical record only supports 1 unit of CPT code 93923. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (93923) provided July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Fitbit tracker.  You asked the Plan to pre-approve . You say that you think the Fitbit should be covered. The Plan denied your request. The Plan says a Fitbit is not covered as it is not primarily a medical device.  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 Fitbit tracker.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on May 22, 2021.

You asked the Plan to pay for the testing services. You say that medical records were provided. The Plan denied your request. The Plan says experimental or investigational 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. 

We looked at the file and the rules. The medical records provided indicate the genetic testing will determine whether a gene mutation would increase risk of cardiovascular disease. This risk testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on May 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0652).  You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.  You asked the Plan to pre-approve SNF services. You say that the enrollee needs therapy. The Plan denied your request. The Plan says that the enrollee does not have a need for daily skilled services that can only be provided at a skilled nursing facility after physical therapy testing.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray provided on June 29, 2021.  You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not 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 71045 is radiologic examination, chest; single view. We find that CPT code 71045 was billed with code 36573. CPT code 71045 may be eligible for payment when billed with this code pair. The claim provided does not indicate the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on June 29, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the FoundationOne CDx Panel provided on January 27, 2021.  You asked the Plan to pay for the FoundationOne CDx Panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the submitted claim is missing information and this testing is considered investigational.  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 pay for the FoundationOne CDx Panel. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found next-generation sequencing (NGS) offers the opportunity to assess numerous mutations simultaneously, along with other molecular events such as amplification, deletions, tumor mutation burden, and microsatellite instability status. These help guide therapy decision making. Use is supported by the NCCN Guidelines. The service is reasonable and medically 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 FoundationOne CDx Panel have been met. Please note, the Plan's denial also states that the claim form is missing required information. The documentation submitted does not include a claim so we are unable to verify this information. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the FoundationOne CDx Panel provided on January 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140), additional intraoral x-ray (D0230), apicoectomy (D3410) and retrograde filling (D3430) provided on February 1, 2021.  You asked the Plan to pay for the dental services. You say that this is not a dental claim and should be processed under your medical benefits, because these services were necessary due to an infection in your mouth. The Plan denied your request. The Plan says only one intraoral x-ray may be covered per calendar year. The first of these x-rays has been covered, but the second one provided on the date in question exceeds your benefit limitation for this service. In addition, the limited oral exam, apicoectomy and retrograde filling are not covered by your dental benefit.  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 or were provided in a frequency that exceeds what is covered by this benefit. You say that these services should be covered by your medical benefit; however, documentation was not provided to verify that these services are not dental in nature. Generally, Medicare does not cover dental services. The services in question were provided by an out-of-network dental provider and were billed with dental codes. You say that these services were provided to treat an infection, but no medical documentation was provided to verify the location of the infection and whether or not these services were provided in relation to the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth as defined by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), additional intraoral x-ray (D0230), apicoectomy (D3410) and retrograde filling (D3430) provided on February 1, 2021.
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 the incontinence supplies is required. The Plan denied your request. The Plan says these supplies are not a covered benefit.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a fully electric hospital bed (E0265).  You asked the Plan to pre-approve the fully electric hospital bed. You say that the hospital bed is necessary. The Plan denied your request. The Plan says it does not cover fully electric hospital beds.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully electric hospital bed (E0265).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device (22869, 22870).  You asked the Plan to pre-approve the insertion of a Vertiflex Superion Interspinous device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for your condition.  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 insertion of a Vertiflex Superion Interspinous device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective.  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 insertion of a Vertiflex Superion Interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visits (99213) provided on February 2, 2021 and July 13, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services provided are not a covered benefit under your contractual policy.  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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visits (99213) provided on February 2, 2021 and July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the upper partial denture (D5211).  You asked the Plan to pre-approve the upper partial denture (D5211). You say that you can't eat anything but liquids and soft food. You say that you are in constant pain and are in dire need of approval for additional dental work. The Plan denied your request. The Plan says dentures are only covered one procedure every five plan years.  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 upper partial denture every five plan years. The Plan paid for the upper partial denture provided on April 25, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue regeneration (D4266).

You asked the Plan to pre-approve the bone replacement graft and guided tissue regeneration. You say that you believe these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefit 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 bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urgent care visit you had on August 2, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that you went to the urgent care but the doctor was unable to help you. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for urgent care services.   You have been asked to pay a $40 copayment for the urgent care visit. This copayment applies regardless of the outcome of the visit. 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 urgent care visit you had on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services (36415, 70450, 71045, 80048, 80053, 80061, 83735, 83880, 84443, 84484, 85025, 85027, 85610, 85730, 93005, 93970, 96365, 96366, 96376, 99285, A9270, C8929, G0378 and Q9957) provided October 19, 2020 to October 20, 2020.  You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider is not eligible for payment.  The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.  We looked at the file and Medicare rules. Records show no active Medicare Certification Number on file for this provider on the dates of service at issue.  Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services (36415, 70450, 71045, 80048, 80053, 80061, 83735, 83880, 84443, 84484, 85025, 85027, 85610, 85730, 93005, 93970, 96365, 96366, 96376, 99285, A9270, C8929, G0378 and Q9957) provided October 19, 2020 to October 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on January 19, 2021, by an out-of-network provider.  You asked the Plan to pay for psychotherapy services. You say that the Plan has covered other claims from the provider of the services at issue. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 psychotherapy services (90832) provided on January 19, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) on May 8, 2021.  You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says the dates on the proof of delivery and the dates of service do not match up.    The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in this case. The shipped date is May 7, 2021, and the delivery date is May 12, 2021. However, the date of service was May 8, 2021. An additional packing slip was included in the order for June. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) on May 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from April 10, 2021, to May 6, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not agree with this bill. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment per admission for inpatient hospital care.   You have been asked to pay a $350 copayment per admission for the inpatient hospital services. 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 services you received from April 10, 2021, to May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on January 19, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0483 provided on November 5, 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 billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 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 5, 2020.