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

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on August 20, 2021.  You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you feel you should not be responsible for the $225.00 charge for the x-ray that the provider is trying to bill you for because you never authorized this charge. The Plan denied your request. The Plan says your benefits for these services have been satisfied and the frequency limitations have been exceeded.  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, comprehensive oral evaluation is limited to one procedure code every three years, and full mouth or panoramic x-rays share a frequency limitation of one procedure code every five years. The record shows that you received a comprehensive oral evaluation (D0150) and a panoramic x-ray (D0330) on June 17, 2019 and your comprehensive oral evaluation and full mouth or panoramic x-rays benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 23, 2021 by a non-participating provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.  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 laboratory services provided on August 23, 2021 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) provided June 28, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you have not paid for colonoscopies in the past and were not aware there would be a copayment for this service. The Plan denied your request. The Plan says the copayment 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 $200 copayment per visit to an ambulatory surgical center. 

You have been asked to pay a $200 copayment for the diagnostic colonoscopy. In this case, the colonoscopy was performed due to a medical history of colonic polyps and is therefore considered diagnostic. This diagnostic colonoscopy 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 diagnostic colonoscopy (45378) provided June 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on June 3, 2021.

You asked the Plan to waive the copayment for these services. You say that the two services were billed for the same date of service. The Plan denied your request. The Plan says the copayment 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 $350 copayment for in-network Medicare-covered surgery or other services provided to you at an outpatient hospital.

Review of the file shows that you received outpatient surgical services on June 3, 2021. You have been asked to pay a $350 copayment for these services. These services fall within the in-network Medicare-covered surgery or other services provided to you at an outpatient hospital 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. The file shows that you received two separate procedures for the date of service at issue. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on June 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.  You asked the Plan to pre-approve 6 home health physical therapy visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 6 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that further skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair expanded controller, harness, and electronic connection device.  You asked the Plan to pre-approve expanded controller, harness, and electronic connection device. You say that these components are medically necessary to meet the enrollee's medical, functional, and mobility needs. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because there is no medical need to control the wheelchair's power options through a joystick.  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 expanded controller, harness, and electronic connection device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the patient does not need to control the power options through a joystick. The enrollee's upper extremity function including ability to perform catheterization support that the enrollee can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expanded controller, harness, and electronic connection device have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair expanded controller, harness, and electronic connection device.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for thoracoscopy services (procedure code 32666) provided to the enrollee on July 1, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the service was billed without the appropriate anatomical modifier.  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 32666 is "Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found the requested code has a bilateral indicator code of "1," indicating that an anatomical modifier is necessary for correct claim adjudication. The record does not indicate that an anatomical modifier was provided. The elements of the coverage criteria are not satisfied.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for thoracoscopy services (procedure code 32666) provided to the enrollee on July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code R0070) provided to the enrollee on May 20, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service was inappropriate for this procedure.  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 Healthcare Common Procedure Coding System (HCPCS) code R0070 is "Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the service was reported with place of service 31 Skilled Nursing Facility. The documentation supports that the enrollee was in the skilled nursing facility - however, the technical component for ancillary services would be included with consolidated billing. Services excluded from consolidated billing are emergency services, inpatient services, and other extensive procedure (such as radiation therapy).  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code R0070) provided to the enrollee on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).  You asked the Plan to pay for a pneumatic compression device. You say that the items were medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 12, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service was not billed as required by coding regulations.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.  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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex procedure is experimental. More research is needed to show safety and efficacy.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the durable medical equipment (L0650, L1851, L2397, E0745) provided on May 3, 2021.  You asked the Plan to pay for the durable medical equipment. You say that you are providing evidence that this equipment was delivered as ordered. The Plan denied your request. The Plan says the enrollee has confirmed that no items were delivered thus payment is not allowed because services were not rendered.  The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L0650, L1851, L2397, E0745) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing provided on February 16, 2021.  You asked the Plan to pay for the services provided. You say that the testing analyzes genetic variations that may affect a response to medications. The Plan denied your request. The Plan says the testing has not been shown to be useful.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics testing is only covered under certain medical indications.   We looked at the file, and Medicare rules. The provided pharmacogenetic testing was reportedly ordered to make decisions about the patient's medications. Medications should be provided based on the presence of a diagnosis and should be adjusted based on the enrollee's response to the medication. It is not necessary to do genetic testing to provide or adjust medications. 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 GeneSight testing provided on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 18, 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 billed are not payable.

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 documentation does not include documentation to support how the enrollee came to the servicing provider,
or whether the services were medically necessary. The documentation did not include medical records from the
servicing provider or the requesting provider. This means that the documentation does not support that the
laboratory services at issue in this appeal were not 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 August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on June 29, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you were told that the extraction (D7210) would be approved at 100%. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you were advised the cone beam CT capture and interpretation was not a covered service during your call with the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services (83036, 80061, 82947, 81003, 87086) provided on August 17, 2021 and August 19, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $10 per day for other Medicare-covered laboratory services that are not FIT tests.
You have been asked to pay $20 ($10 copayment x 2 days) for the Medicare-covered laboratory services 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 copayments for the laboratory services (83036, 80061, 82947, 81003, 87086) provided on August 17, 2021 and August 19, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided on August 18, 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 there were network providers available.

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 (80307) provided on August 18, 2021.