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

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periodontal maintenance (D4910) and a topical application of fluoride varnish (D1206) provided on August 5, 2021.

You asked the Plan to pay for dental services. You say that you have opted out of Medicare because services you provide are typically not covered by Medicare however, you have not opted out with the Plan. The Plan denied your request. The Plan says the requested provider has opted out of Medicare.

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. Specifically, we have confirmed that you opted out of Medicare on December 1, 2020. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), periodontal maintenance (D4910) and a topical application of fluoride varnish (D1206) provided on August 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on January 1, 2021.

You asked the Plan to pay for the hospital discharge day management. You say that you would like this claim to be processed and paid. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on January 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the continuous positive airway pressure (CPAP) device supplies, provided on October 3, 2021.

You asked the Plan to waive the copayment for the CPAP supplies. You say that the item should be covered. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for durable medical equipment (DME) and supplies. 

You have been asked to pay a 20% coinsurance for the CPAP supplies. This item falls within the durable medical equipment (DME) and 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 copayment for the continuous positive airway pressure (CPAP) device supplies, provided on October 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for SelectMDx (CPT code 81479) provided to the enrollee on August 26, 2021.  You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service was not necessary.  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.  Medicare recognizes that evidence for clinical utility for: CPT 81479 - SelectMDx in males with previous negative prostate biopsy who are being considered for repeat biopsy is promising with evidence of some clinical utility to reduce unnecessary repeat prostate biopsies. There was no documented result of prior prostate biopsy. There was no documented significant interval increase in PSA level. Therefore, we decided that the Plan does not have to pay for SelectMDx (CPT code 81479) provided to the enrollee on August 26, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency department visit for the evaluation and management of a patient (CPT code 99284) provided to the enrollee on March 29, 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 claim already processed and paid.  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 the enrollee was seen in the emergency department (ED) on March 29, 2021. The submitted documentation supports 1 (one) unit of 99284, which was previously approved/paid. There is no additional documentation supporting additional services which were billed and remain denied. 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 emergency department visit for the evaluation and management of a patient (CPT code 99284) provided to the enrollee on March 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hyperbaric oxygen under pressure, full body chamber (G0277), provided on June 9, 2021, through July 27, 2021.

You asked the Plan to waive the copayment for the hyperbaric oxygen under pressure, full body chamber. You say that there should not be a copayment. The Plan denied your request. The Plan says the cost share 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 $50 copay for outpatient hospital services other than surgery for outpatient hospital services. 

You have been asked to pay a $50 copay for outpatient hospital services other than surgery for the hyperbaric oxygen under pressure, full body chamber. the hyperbaric oxygen under pressure, full body chamber falls within the outpatient hospital services 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 hyperbaric oxygen under pressure, full body chamber (G0277), provided on June 9, 2021, through July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) and problem focused limited oral evaluation (D0140) provided on June 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the surgical extraction and problem focused limited oral evaluation. You say that you contacted the Plan for dentists in your area, were given 3 or 4 names, and chose this treating provider which was one that was given to you by the Plan. You also say that you did not receive an emergency appointment, and this was the only time you had this evaluation. The Plan denied your request. The Plan says the surgical extraction was processed, and a 50% coinsurance was applied in the amount of $124. The Plan says that your benefits for the problem focused limited oral evaluation are limited to one time per calendar year. The Plan also says that at no time were you referred to this OON provider by 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, you are responsible for 50% of billed charges up to the $1,000 allowance for all covered dental services received OON. The Plan contract also says that you are limited to 1 emergency diagnostic exam per year. The record shows that you received a problem focused limited oral evaluation (D0140) on May 26, 2021 and your emergency diagnostic exam benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210) and problem focused limited oral evaluation (D0140) provided on June 4, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 22, 2021, through August 19, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share 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 $225 copayment per each one-way trip for ambulance service. 

You have been asked to pay a $225 copayment per each one-way trip for the ambulance services. This service falls within the ambulance service 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 ambulance services provided on June 22, 2021, through August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology services provided on June 25, 2021.  You asked the Plan to pay for the services provided. You say that the service is now the standard of care. The Plan denied your request. The Plan says the rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The technical component of a pathology service is not payable for a hospital inpatient or outpatient. 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 pathology services provided on June 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography and somatosensory testing (95861, 95938) provided on May 27, 2021.  You asked the Plan to pay for the needle electromyography and somatosensory testing. You say that you would like reconsideration because these services are payable per Medicare. The Plan denied your request. The Plan says hospital bundling rules exclude payment to suppliers of the Technical Component (TC) or a radiology service for beneficiaries in a hospital inpatient stay.  The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the needle electromyography and somatosensory testing have not been met. Specifically, the record indicates that this member was in a hospital inpatient stay on the billed date of service. Payment for the TC of these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the needle electromyography and somatosensory testing (95861, 95938) provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 26, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the documentation is missing required information.
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 L0650 is lumbar-sacral orthosis, sagittal-coronal control,
with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t -9 vertebra,
lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen
design, prefabricated, off-the-shelf.
We find that CPT code L0650 is not supported in the medical record. Specifically, the enrollee's medical record
must contain sufficient documentation of the enrollee's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information
should include the enrollee's diagnosis and other pertinent information including, but not limited to, duration of
the enrollee's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional
limitations, other therapeutic interventions and results, past experience with related items, etc. The
documentation does not include this required information. This means that the enrollee's medical record does
not adequately support the medical necessity for the item rendered. Based on this information, we decided that
Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office services provided on July 19, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office services. You say that you disagree with the denied claim. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office services provided on July 19, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).  You asked the Plan to pre-approve a spinal cord stimulator. You say that this device is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is subject to the criteria listed in the Medicare rules section.  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 a spinal cord stimulator. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found that the enrollee is a 67-year-old woman who has chronic low back pain. She had physical therapy and did a home exercise program. She has had radiofrequency ablation for facet mediated pain. She takes Lyrica and Cymbalta for pain. She has psychological clearance for a spinal cord stimulator. She has not had prior spine surgery or other evidence-based indication for a spinal cord stimulator. In this case, the enrollee does not have an evidence-based indication for a spinal cord stimulator trial. The request 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99203) provided on July 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that this was authorized by Veterans' Affairs. The Plan denied your request. The Plan says this was not authorized by the Plan.  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 an office visit (99203) provided on July 9, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 29, 2020.
You asked the Plan to pay for this service. 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. We overturned the Plans denial based on the Plan contract provided. The Plan requested a reopen and provided the correct Plan contract the enrollee is a member of.
The Plan is correct in this case. 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 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, 87801) provided on June 3, 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 (87481, 87496, 87500, 87529, 87532, 87640, 87653, 87798, 87801) provided on June 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (G0151) provided on July 16, 2021, through August 10, 2021.

You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says manifestation codes cannot be billed as first listed diagnosis on claim.

The Plan must follow Medicare rules. Medicare rules say that the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, this claim was billed with F02.80 as the primary diagnosis. This diagnosis code has a code first note meaning that diagnosis code for the underlying condition must be sequenced first. Therefore, we decided that the Plan does not have to pay for the physical therapy services (G0151) provided on July 16, 2021, through August 10, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for office services provided on September 14, 2021.

You asked the Plan to pay for office services. You say that you do not understand why you have to pay for this and have never paid for it before. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these services were required by a third party which is excluded from Medicare coverage.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

These services were performed by an in-network provider. The file does not show that the Plan provided notice that office services would not be covered. Although Medicare excludes coverage for examinations required by third parties, the Plan has not submitted sufficient evidence to prove that this examination was a direct requirement of a third party. The record shows that you were applying to adopt a dog, but does not show that a specific third party organization or government agency was requiring you to obtain these services. Under Medicare rules, this means office services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for office services provided on September 14, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.