Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception provided on June 1, 2021.

You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception. You say that the services were medically necessary. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 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 neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on December 15, 2020.

You asked the Plan to pay for the dental services. You say that you need an emergency dental exam. You say that you had to go to an out of network dentist due to the coronavirus. You also say that you would appreciate some help and a resolution. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered dental service. The Plan says that periapical x-rays are not listed as covered dental services either.

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 limited oral evaluation and periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on December 15, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the monthly rental charge for portable oxygen tanks provided
on March 25, 2021.

You asked the Plan to pay for the portable oxygen tank rental charge. You say that this equipment is medically
necessary and should be covered. The Plan denied your request. The Plan says the enrollee had an active
hospice election on this date of service. The services are not payable by the managed care plan.

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 monthly rental charge for portable oxygen tanks provided
on March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy (Microfragmented Adipose Tissue (MFAT) procedure).

You asked the Plan to pre-approve knee arthroscopy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that Microfragmented Adipose Tissue (MFAT) injection in the knee is not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy (Microfragmented Adipose Tissue (MFAT) procedure).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 24,
2021, to May 27, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told that there
would be no cost for hospital stays with this Plan. The Plan denied your request. The Plan says the copayment
you are being charged is correct.
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 $325
copayment per day, for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says you
pay a $0 copayment per day, for days 6 to discharge.
You have been asked to pay a $325 copayment per day for inpatient hospital care. The records show that you
were inpatient for three (3) days for a total cost share of $975 ($325 x 3 days = $975). The EOC confirms that
$325 is the required copayment for this service. 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 inpatient
hospital care provided on May 24, 2021, to May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from March 3,
2021, through April 9, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully
support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken
and the code should be reprocessed for prompt payment. The Plan denied your request. The Plan says bundled
services are not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff
time over and above those usually included in an office visit or other non-facility service(s), when performed
during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status
indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on
this information, we decided that Medicare rules for coverage of the additional supplies and materials have not
been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials
provided from March 3, 2021, through April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan.

You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that the documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician reviewer found the documentation shows that recent Retuxan treatment was not successful at treating left lower extremity weakness. The requested positron emission tomography (PET) scan was approved and is appropriate considering your symptoms and need for support for next clinical steps. However, CT would not significantly add information to the PET scan results or help to make a next clinical decision. Therefore, you do not meet criteria for the requested CT scan. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sit to stand lift (E0637).

You asked the Plan to pre-approve a sit to stand lift. You say that the standard patient lift is a more passive device and does not provide any exercise benefit. The Plan denied your request. The Plan says this item is not covered as a sit to stand lift does not service a primarily medical function.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does 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 sit to stand lift (E0637).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oral function therapy provided on December 18, 2019.

You asked the Plan to pay for oral function therapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code was not billed in accordance with medically unlikely edits policy.

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 92526 is 1. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of oral function therapy have not been met. Therefore, we decided that the Plan does not have to pay for oral function therapy provided on December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 1, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you saved the Plan a lot of money by not going to the emergency room, and you wanted to be seen by your doctor instead of an emergency room physician. You say that you went to see your doctor the next day and they performed a lot of tests. The Plan denied your request. The Plan says ambulance services without transport are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 1, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram you had on May 20, 2021.

You asked the Plan to waive the copayment for the mammogram. You say that this mammogram was a second one done as a follow-up to a routine screening. You said that there should be no copayment for this. The Plan denied your request. The Plan says you already received a screening mammogram at no cost to you. This second mammogram based done based on the findings from the initial mammogram, so the copayment 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 copayment for flat-film x-rays and ultrasounds. 

Records show that you had a screening mammogram on April 27, 2021. You were not charged a copayment for this service. During that mammogram, there were abnormalities found that produced an inconclusive result. Because of this, your doctor ordered a second mammogram for you.

According to your Evidence of Coverage, you are entitled to one mammogram every 12 months at no charge. Because this was the second mammogram you had within the 12-month period, you are required to pay a copayment. You have been asked to pay a $20 copayment for the mammogram. The mammogram falls within the flat-film x-rays and ultrasounds 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 mammogram you had on May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the retainer crown (D6740) for tooth # 21, and pontics (D6245) for teeth # 19 and 20 provided on December 29, 2020.

You asked the Plan to pay an additional amount for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says there is a $2,000 annual maximum benefit for covered dental services. The Plan also says that the annual maximum benefit has been exhausted.

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 services could be covered, the annual maximum benefit has been exhausted in the processing of this claim. The record shows that the Plan paid $129 for services performed on December 7, 2020, and $73 for dental services performed on December 18, 2020. The record shows that the Plan paid $1,798 towards the dental services you received on the date of service in this case. $129+$73+$1,798=$2,000.

Therefore, we decided that the Plan does not have to pay an additional amount for the retainer crown (D6740) for tooth # 21, and pontics (D6245) for teeth # 19 and 20 provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99153), the Venography (75827), and the Fluoroscopic guidance for central venous access device placement (77001) provided on March 30, 2021.

You asked the Plan to pay for codes 99153, 75827, and 77001. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 75827 and 77001 have a bundled relationship with code 37248 and cannot be paid as billed. These codes cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. 

The review also shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153), the Venography (75827), and the Fluoroscopic guidance for central venous access device placement (77001) provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says your
medical needs are being met in the current acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found in this case, you were admitted to the acute care hospital with ischemic strong and required
thrombolysis. The record indicates that your hospital course was complicated by aortobifemoral occlusion.
The record indicates that you are no longer ventilator dependent and have wound vacs in place that are changed
at intervals. You continue to receive acute care services, and these have not been denied. The medical record
does not indicate that you require services that you are not currently receiving but that would be available at the
LTACH facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311) and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the enrollee really needs this authorization to be approved due to the fact that the enrollee cannot walk on their own and had a spinal cord injury. The Plan denied your request. The Plan says the DME is not necessary.

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 DME have not been met. The seat lift does not serve a primary medical purpose. The upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve power seat elevation system (CPT code E2300), expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311) and harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the second screening mammography.

You asked the Plan to pay for screening mammography, bilateral (77067-TC). You say that the Plan should pay this claim. The Plan denied your request. The Plan says despite multiple outreaches the provider has not submitted any clinical records to support the medical necessity of the service.

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 77067-TC is screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. 

We find that CPT code 77067-TC is not supported in the medical record. Specifically, there are no medical records from the provider in the case file. Based on this information, we decided that Medicare rules for coverage of screening mammography, bilateral (77067-TC) have not been met. Therefore, we decided that the Plan does not have to pay for the second screening mammography.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the urinalysis (81001) and X-ray exam (71046) provided on May 10, 2021.

You asked the Plan to pay for the lab services. You say that you would like these claims reprocessed as separate payments not included in the inpatient claims. The Plan denied your request. The Plan says that when outpatient services are performed the day before an inpatient admission, these claims are treated as inpatient 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. 

We find that these services are supported in the medical record. Specifically, these claims were both billed with a point-of-service code of 22 representing services received while the patient was considered outpatient. Although a facility must include all outpatient services provided 3 days prior to inpatient admission on an inpatient claim, the physician who provided these services would not need to report the inpatient point-of-service code. Therefore, point-of-service code 22 would be correct in this situation. These services are separately payable according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have been met. Therefore, we decided that the Plan has to pay for the urinalysis (81001) and X-ray exam (71046) provided on May 10, 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.