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

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), treatment simulation using 3D image volume (D0393), and endodontic therapy (D3310) provided on May 18, 2021 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, treatment simulation using 3D image volume, and endodontic therapy. You say that you contacted every dentist who does root canals within an extended area over several counties and were denied any emergency service for months. You also say that you were in excruciating pain, it was an emergency, and you had no alternative. The Plan denied your request. The Plan says services performed by an OON provider are not covered because your healthcare plan does not have OON benefits. The Plan also says that the treatment simulation using 3D image volume 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, you are responsible for 100% of the
cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), treatment simulation
using 3D image volume (D0393), and endodontic therapy (D3310) provided on May 18, 2021 by an OON
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the Intracept procedure. The Plan denied your request. The Plan says this is not medically necessary.

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 Intracept procedure. Our reviewer says that the Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that this is an experimental/investigational procedure.  Therefore, the request is considered 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on June 21, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you did not pick-up the device until June 23, 2021. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. The record shows that you had DME and related supplies on June 21, 2021. The total allowed amount is $117.65 and 20% of that is $23.53.
You have been asked to pay the total coinsurance amount of $23.53 for DME and related supplies. DME and
related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies provided on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on April 5, 2021.
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the reasonableness of the equipment has not been established.
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. The file shows that a back, knee, and wrist orthoses were provided. We looked at the file and Medicare rules. The Plan states that the orthoses 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses provided on April 5, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99284) provided on February 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code and 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 99284 has a bundled relationship with code 99285 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 services (99284) provided on February 22, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on November 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function". 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 use of code 99285 is not supported by the records provided. Our reviewer found that the emergency room visit does not support CPT 99285 level of service. The documentation supports a comprehensive history and exam, however, the documentation also supports medical decision making of moderate complexity, with radiology, lab work and IV fluids with additives. In this case, CPT 99284 is a more appropriate code to report for the services provided. 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 the services (99285) provided on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 4, 2021.
You asked the Plan to pay for the limited oral evaluation (D0140). You say that you received notice that the oral evaluation was denied, and you are requesting the guidelines used to make this decision. The Plan denied your request. The Plan says code D0140 has a frequency limit of one procedure per plan year.
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 limited oral evaluation per plan year. The Plan paid for the limited oral evaluation provided on February 23, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided
on April 12, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you paid the
$35 copayment and were not informed that you would owe additional charges. The Plan denied your request.
The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug injection on April 12, 2021. The total allowed amount is $1,205.64 and
20% of that is $241.13.
You have been asked to pay the total coinsurance amount of $241.13 for a Medicare Part B drug injection. A
Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular profile (81404, 81405, 81406) provided on February 19, 2021. You asked the Plan to pay for a hereditary cardiovascular profile. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular profile have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular profile (81404, 81405, 81406) provided on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician evaluation and management provided on January 28, 2021.
You asked the Plan to pay for initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (G0245). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the records show the enrollee does not have diabetes therefore the test was not medically necessary.
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 G0245 is initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (lops) which must include: (1) the diagnosis of lops, (2) a patient history, (3) a physical examination that consists of at least the following elements: (a) visual inspection of the forefoot, hindfoot and toe web spaces, (b) evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear and (4) patient education. We find that CPT code G0245 is not supported in the medical record. Specifically, the medical records do not show that the enrollee is diabetic. Based on this information, we decided that Medicare rules for coverage of initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (G0245) have not been met. Therefore, we decided that the Plan does not have to pay for the physician evaluation and management provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vasopneumatic device therapy procedure and
subcutaneous injection provided on January 20, 2021.
You asked the Plan to pay for vasopneumatic device therapy procedure represented by codes 99211, 97112,
96372, and subcutaneous injection represented by codes J3490, J3420, J3415, J3411, and J1955. You say that
the enrollee needed the procedures because the enrollee has pain with numbness and tingling bilateral feet. The
Plan denied your request. The Plan says there is no mention of edema in chart notes and these procedures are
considered investigational and not eligible for coverage for the treatment or neuropathies or peripheral
neuropathies caused by underlying systemic diseases.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The device is to reduce edema or lymphedema, treatment of
peripheral neuropathy with this device is not considered medically reasonable and necessary. Based on this
information, we decided that Medicare rules for coverage of vasopneumatic device therapy procedure
represented by codes 99211, 97112, 96372, and subcutaneous injection represented by codes J3490, J3420,
J3415, J3411, and J1955 have not been met. Therefore, we decided that the Plan does not have to pay for the
vasopneumatic device therapy procedure and subcutaneous injection provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (99213) provided to the enrollee on July 13, 2020.
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 Entity the services rendered were telehealth services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99213 is "Evaluation and management of an established patient in an office or outpatient location for 15 minutes." 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 provider billed services with a place of service of 11 for office. The services should be reported with place of service 02 for telehealth, to indicate that the services were provided from a distant site. 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 telehealth services (99213) provided to the enrollee on July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extractions provided on April 12, 2021.
You asked the Plan to pay for the extractions. You say that the dental office advised you insurance would take care of part of the procedure. The Plan denied your request. The Plan says services performed by an out-of-network provider are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The file shows that you received extractions from an out-of-network provider. We looked at the file, and Medicare rules. Your plan only covers extractions when provided by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the extractions have not been met. Therefore, we decided that the Plan does not have to pay for the dental extractions provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99291) provided on March 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has been exceeded. The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 services (99291) provided on March 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not urgent or emergent.
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 services 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 the services provided by an out-of-network provider on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show test results and medical notes from two diagnostic medial branch block procedures.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had a diagnostic block in May 2021 that provided 70% relief for one week. The elements of the coverage criteria are not satisfied. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from February 21, 2021 to February 24, 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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that 'to' and 'from' dates are required on the CMS-1500 claim form. We looked at the file and Medicare rules. The file shows that the claim was not submitted with the 'to' and 'from' dates on the claim form properly filled out. 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 services rendered from February 21, 2021 to February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 26, 2021.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no evidence of a relationship between the enrollee and ordering physician and the documentation submitted does not include an order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 26, 2021.