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

 We decided that the Plan does not have to pay for the medical services (99053) provided on April 19, 2021.  You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the medical services (99053) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81226, 81241, 81240, 81230, 81291, 81335) provided on February 25, 2021.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81226, 81241, 81240, 81230, 81291, 81335) provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97530) provided on June 3, 2021.

You asked the Plan to pay for occupational therapy services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that the services of Occupational Therapy Assistants (OTAs) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.

We looked at the file and Medicare rules. The record shows that the services at issue were provided by an OTA and billed by a nurse practitioner. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (97530) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on October 21, 2020.

You asked the Plan to pay for genetic testing. You say that this testing meets the criteria for coverage. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided March 11, 2021.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that SelectMDx testing is covered in males with previous negative prostate biopsy who are being considered for repeat biopsy. 

We looked at the file and Medicare rules. The record does not show a prior negative prostate biopsy. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), porcelain crown (D2740), core build up (D2950), oral or facial photographic images (D0350 x 3), and complete series x-ray (D0210) provided from August 12, 2021, to August 23, 2021.
You asked the Plan to pay for the dental services. You say that this bill is too much. You say that you were not expecting a dental bill. You say that your yearly dental benefit covers $2,500 a year and you are expected to pay $1,830. You also say that you cannot pay because you do not have a job currently and no way to pay. The Plan denied your request. The Plan says comprehensive oral evaluation, complete series x-ray, and panoramic x-ray are covered once every 3 plan years. The Plan says crowns and core build up are covered once per tooth every 5 plan years. The Plan says that these frequency limits have been exceeded. The Plan also says that oral or facial photographic images are not covered services.
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 and the comprehensive oral evaluation, panoramic x-ray, complete series x-ray, crown and core build up are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a crown and core build up for tooth # 20 that you received on August 28, 2018. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on June 29, 2020. The record shows that the Plan paid for a panoramic x-ray that you received on April 21, 2021. Additionally, the oral or facial photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), porcelain crown (D2740), core build up (D2950), oral or facial photographic images (D0350 x 3), and complete series x-ray (D0210) provided from August 12, 2021, to August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of inpatient care provided from June 29, 2021, through July 1, 2021.  You asked the Plan to pay for continuation of inpatient care. You say that care was medically necessary. The Plan denied your request. The Plan says dates of service from June 29, 2021, through July 1, 2021 are denied because the member was determined to be medically stable as of June 28, 2021.  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 pay for continuation of inpatient care. Our reviewer says that the inpatient care provided after June 28, 2021 was not considered medically reasonable and necessary in this case. Our physician reviewer found that the medical documentation indicates that the enrollee stayed in the hospital until July 1, 2021 as nursing home placement was being arranged and those extra days were not medically necessary for hospitalization. The review has determined that continuation of the inpatient care past June 28, 2021 was not medically reasonable or 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 continuation of inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for continuation of inpatient care provided from June 29, 2021, through July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a genicular nerve block (CPT code 64454) provided to the enrollee on July 12, 2021.
You asked the Plan to pay for the service. You say that the clinical reports clearly demonstrate medical necessity for the pain management treatment. The Plan denied your request. The Plan says the clinical value and effectiveness of a genicular nerve block in the setting of knee osteoarthritis have not been demonstrated in the peer-reviewed literature.
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 pay for the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block of the right knee is not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not have to pay for a genicular nerve block (CPT code 64454) provided to the enrollee on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from June 1, 2021, through
June 2, 2021.
You asked the Plan to pay for inpatient hospital care. You say that it is not your responsibility to have the
hospital claims department bill accordingly. The Plan denied your request. The Plan says records show that a
prior authorization for the knee surgery had been made for services to be performed under outpatient or
observation status. The Plan states upon review of the clinical documentation received, the Plan found that
there were no noted intraoperative complications documented; therefore, not supporting the need to switch to
inpatient care for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Review of the file shows that a prior authorization for the knee surgery had been made for services as outpatient or observation status, and clinical documentation does not support the need to switch to inpatient. You are not liable for paying for an inpatient admission as that would be balance billing and is not permitted under either original Medicare or Medicare Advantage. If the hospital resubmits the claims for services as outpatient, the Plan will reimburse the hospital at contracted rates for the services related to the knee surgery. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from June 1, 2021, through June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on July 12, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on July 12, 2021.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 19, 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 August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on May 4, 2021.

You asked the Plan to pay for the services provided. You say that the physician provided services in good faith. 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. 

We looked at the file and the rules. The file shows that CPT code 11720 may be eligible for payment when billed with code 11056. We find that CPT code 11720 was not billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive orthodontic treatment of the adult dentition (D8090) provided on July 14, 2021.
You asked the Plan to pay for the comprehensive orthodontic treatment. You say that this claim resulted from a medical emergency and is unrelated to dental care. The Plan denied your request. The Plan says this is a non-covered service.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive orthodontic treatment of the adult dentition (D8090) provided on July 14, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair van transportation (A0130) and wheelchair
van mileage (S0209) provided on April 25, 2021.
You asked the Plan to pay for the wheelchair van transportation and mileage. You say that you were sent home
from the hospital in a wheelchair van, rather than waiting for someone to pick you up. You also say that you
did not need the van, could have driven yourself if you had a car available, and feel that you did not even need
a wheelchair. The Plan denied your request. The Plan says you were transported by non-emergency wheelchair
van services from the hospital to your residence. The Plan also says that non-ambulance transportation is only
covered from a hospital to a skilled nursing facility, and this request cannot be approved.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided
that the Plan does not have to pay for the wheelchair van transportation (A0130) and wheelchair van mileage
(S0209) provided on April 25, 2021.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing for the x-ray services. We decided that the Plan does not have to waive the cost-sharing for injection/surgical supplies and office visit services.
You asked the Plan to waive the cost-sharing for x-ray, injection/surgical supplies, and office visit services. You say that you were not made aware of the cost-sharing beforehand. The Plan says that the cost-sharing applied correctly based on the services rendered.
We decided that the Plan has to reduce the cost-sharing for x-ray services.
The Plan applied a $110 copayment for "outpatient diagnostic services" (77002), the short descriptor of the guidance code 77002 is "needle localization by x-ray" with the long descriptor saying, "Fluoroscopic guidance for needle placement". According to the Food and Drug Administration (FDA), "Fluoroscopy is a type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie." Based on this description we have found that the $15 x-ray copayment would be more appropriate. Therefore, we decided that the Plan has to reduce the cost-sharing for x-ray services.
We also decided that the Plan does not have to waive the cost-sharing for injection/surgical supplies and office visit services.
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 20% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and a $30 copayment for Physician/Practitioner Services, Including Doctor's Office Visits, specifically Specialist Office Visits Therefore, we decided that the Plan does not have to waive the cost-sharing for injection/surgical supplies and office visit services.
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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on May 13, 2021.  

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transitional care management services (99496) provided on August 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the transitional care management services. You say that your physician's re hospitalists that render medical care for the patients in the hospital as requested by the hospital. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 transitional care management services (99496) provided on August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from April 9, 2021 to April 14, 2021 and billed under code S9500.
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 code S9500 has a status indicator of "I" which prevents payment on Medicare claims.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this code cannot be paid based on the status code indicator. Medicare uses another code for reporting these services. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from April 9, 2021 to April 14, 2021 and billed under code S9500.