Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on January 26, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed by the provider.
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 the service has a bundled relationship 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 anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental
pneumatic appliance (E0668).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that due to poor
results with the basic pump, and severity and location of her swelling, the advanced Flexitouch pneumatic
compression device has been prescribed as the only effective treatment for this enrollee. The Plan denied your
request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there
is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

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 pre-approve a pneumatic compression device
(E0652) and segmental pneumatic appliance (E0668).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) for tooth #30.
You asked the Plan to pre-approve a bone replacement graft. You say that this service is necessary. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263) for tooth #30.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry testing provided on April 27, 2021, billed with code 88342.
You asked the Plan to pay for the immunohistochemistry testing as billed. You say that this code 88342 should be paid. The Plan denied your request. The Plan says this was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that ff a provider reports two codes of an edit pair, only the Column 1 code is payable. For edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
CPT code 88342 is a Column 2 code in relation to code 88360 which was billed on this claim. No appropriate NCCI modifier was reported with 88342. As such, the denial of payment is supported. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the immunohistochemistry testing as billed have not been met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry testing provided on April 27, 2021, billed with code 88342.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care supervision (99380) provided on
March 26, 2021.
You asked the Plan to pay for the nursing facility care supervision. You say that you would like reconsideration
because the provider rendered medically necessary services. The Plan denied your request. The Plan says CPT
code 99380 has a status indicator of B.
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 99380 is supervision of a nursing facility patient (patient
not present) requiring complex and multidisciplinary care modalities involving regular development and/or
revision of care plans by that individual, review of subsequent reports of patient status, review of related
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care
decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian)
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment
plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.
We find that CPT code 99380 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 99380 has a status indicator of B. This means that payment for CPT code 99380 is always bundled into
another service or procedure. Based on this information, we decided that Medicare rules for coverage of the
nursing facility care supervision have not been met. Therefore, we decided that the Plan does not have to pay
for the nursing facility care supervision (99380) provided on March 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the arthrocentesis procedure and the Euflexxa medication you received at an outpatient hospital facility on June 1, 2021.
You asked the Plan to waive the cost sharing for the arthrocentesis procedure and the Euflexxa. You say that you believe this was done in an office, so you shouldn't have to pay this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that the allowed amount for the arthrocentesis procedure ($136.83) is less than your copayment obligation, so you are responsible for the full allowed amount for that service.
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 $275 copayment for services at an outpatient hospital facility and 20% coinsurance for Medicare Part B drugs.
The claim information indicates that the facility where these services were performed is considered an
outpatient hospital facility. You have been asked to pay a $275 copayment for the arthrocentesis procedure and
20% coinsurance for the Euflexxa. The arthrocentesis procedure falls within the services at an outpatient
hospital facility benefit category and the Euflexxa falls in the Medicare Part B drug 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 cost sharing for the arthrocentesis procedure and the Euflexxa medication
you received at an outpatient hospital facility on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for nail trimming (11719) provided on March 18, 2021.
You asked the Plan to pay for nail trimming. You say that this was medically necessary. The Plan denied your
request. The Plan says this is not separately payable 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 11719
has a bundled relationship with code 11042 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 nail trimming (11719) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on December 7, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed by the provider.
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 the services has a bundled relationship with another code 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 the anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on December 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for inpatient hospital services from February 21, 2020, through February 25, 2020.
You asked the Plan to pay an additional amount for inpatient hospital services from February 21, 2020, through February 25, 2020. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says the billing of secondary diagnosis code A41.51-Sepsis due to Escherichia coli (E. coli) is not supported.
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 with a secondary diagnosis of A41.51-Sepsis due to Escherichia coli (E. coli). 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 an additional amount for inpatient hospital services from February 21, 2020, through February 25, 2020. Our reviewer says that the medical records do not support the billing of secondary diagnosis code A41.51-Sepsis due to Escherichia coli (E. coli). Our physician reviewer found the medical record received and available for review did not support the condition treated as consistent with a systemic infectious process. 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 an additional amount for inpatient hospital services from February 21, 2020, through February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application of a modality to 1 or more areas; infrared (CPT code 97026-GP) provided to the enrollee on March 19, 2021.
You asked the Plan to pay for the service. You say that according to the benefit verification, the enrollee has acupuncture benefits under the health plan. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture and related services are not covered benefit by Medicare, except for chronic low back pain in this member's coverage document. All types of acupuncture including dry needling for any other condition is non-covered by Medicare. Diagnoses: Diagnoses: M25.511 - Pain in right shoulder. Therefore, we decided that the Plan does not have to pay for application of a modality to 1 or more areas; infrared (CPT code 97026-GP) provided to the enrollee on March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power standing feature (E2301) with accessory components (K0108) and a fender with lights (K0108).
You asked the Plan to pre-approve a power standing feature with accessory components and a fender with lights. You say that you need your wheelchair for more than sitting. The Plan denied your request. The Plan says these items are 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 rules also say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. The items at issue in this appeal do 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 power standing feature (E2301) with accessory components (K0108) and a fender with lights (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compression rental (E0570) rendered by
the OON provider on August 15, 2020.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial
for payment. The Plan denied your request. The Plan says this item was rendered by an out of network
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue.
We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan
does not have to pay for the nebulizer with compression rental (E0570) rendered by the OON provider on
August 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture and unspecified removable prosthodontic procedure provided on May 7, 2021.

You asked the Plan to pay for the unspecified removable prosthodontic procedure. You say that you haven't filed a dental claim for dentures and don't understand why none of the bill was covered. You say that you are covered for 30% of the dentures and the bill should be checked for anything else that might be covered. The Plan denied your request. The Plan says the claim reprocessed to approve the upper denture and the unspecified removable prosthodontic procedure is not a covered 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 unspecified removable prosthodontic procedure is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete upper denture and unspecified removable prosthodontic procedure provided on May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on January 19, 2021.

You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that, when the enrollee's plan was up for renewal, you were told that you would not be responsible for the 20% for chemotherapy. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B chemotherapy drugs. 

The enrollee has been asked to pay $1,936.26, which is 20% of the allowed amount for chemotherapy drugs ($9,681.29 allowed amount x 20% coinsurance = $1,936.26).

Chemotherapy drugs falls within the Medicare Part B Prescription Drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on June 3, 2021.
You asked the Plan to pay for the unspecified preventive service. You say that you always get 2 cleanings and 1 set of x-rays per calendar year. You say that you have been seeing this dentist since 2019. You also say that you were not told that this provider was no longer in your network. The Plan denied your request. The Plan says unspecified preventive service is not listed and therefore is not a covered service. 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 unspecified preventive service is not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 3, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with written report (CPT code 85060) provided to the enrollee on February 26, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed by the provider.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met.
Review of the file shows that CPT code 85060 was billed with a POS 22- Outpatient Hospital. The rules say that procedure code 85060 describes a physician interpretation for service and is not appropriate in Place of Service (POS) 22. Per the 2021 Physician Fee schedule this code has a PC/TC indicator of 8, and per the Claims Processing Manual, Chapter 23 Section 50.6; a PC/TC indicator of 8 means, Physician interpretation codes: This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. This applies only to code 85060. No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. Therefore, we decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with written report (CPT code 85060) provided to the enrollee on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on March 9, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that ConfirmMDx is covered for males aged 40 to 85 years
old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered
for a repeat biopsy due to persistent or elevated cancer-risk factors
We looked at the file and Medicare rules. The file shows that the testing was performed for a first biopsy and
not for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx
testing rendered on March 9, 2021.