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

We decided that the Plan does not have to pay for the physical therapy (PT) services provided in the home on June 30, 2020.
You asked the Plan to pay for the PT services. You say that this should be covered as it was medically necessary. The Plan denied your request. The Plan says the incorrect code was used for this service.
The Plan must follow Medicare rules. Medicare rules say that for physicians or NPPs to bill for the services of auxiliary staff as incident-to services, there must be direct supervision. The services of the PT have been billed by an NPP. This NPP was not present in the home when the services were rendered. As such, the rules for coverage of these services as billed are not met. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided in the home on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 16, 2021.
You asked the Plan to pay for the limited oral exam to evaluate a problem. You say that this service was medically necessary. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the limited oral exam to evaluate a problem once per year. We looked at the file and Medicare rules. The Plan provided documentation showing that this service was previously covered on February 23, 2021. Based on this information, we decided that the Plan's frequency limit
for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power operated wheelchair and accessories.
You asked the Plan to pre-approve a group 2 power operated wheelchair and accessories. You say that this is medically necessary for your condition. 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 PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 group 2 power operated wheelchair and accessories. Our reviewer says that the requested wheelchair is not medically reasonable and necessary. Our physician reviewer found although the medical records indicate that you have a mobility deficit that cannot be overcome with a walker or cane, you are able to operate a manual wheelchair at this time. In addition, you
say you are unable to use the power wheelchair in her home due to carpet. Furthermore, the documentation does not reveal an objective home evaluation with measurements indicating that you can safely maneuver the requested wheelchair in the home and that it will significantly improve MRADLs in the home. The criteria for coverage for the requested wheelchair and accessories have not been met. 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 group 2 power operated wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated wheelchair and accessories
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services (office visit charge) provided on August 30, 2021, by a chiropractor.

You asked the Plan to pay for the chiropractic office visit charge. You say that this should be paid since this provider's treatment is necessary for your recovery. The Plan denied your request. The Plan says Medicare only pays chiropractors for the manual manipulation of the spine. Office visit charges are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the evaluation and management services (office visit charge) provided on August 30, 2021, by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation therapy rendered on January 15, 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 services were not billed correctly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code.

We looked at the file and Medicare rules. The file shows that diagnosis code Z51.0 was incorrectly billed as an 
additional diagnosis and not a primary diagnosis. Therefore, we decided that the Plan does not have to pay for
the radiation therapy rendered on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder Monitor testing panel provided on July 14, 2021.
You asked the Plan to pay for the CxBladder Monitor panel. You say that this test was allowed for coverage in a recent Novitas decision. This is a medically necessary test that should be reimbursed. The Plan denied your request. The Plan says this is not medically necessary. It is considered experimental at this time.
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 CxBladder Monitor panel. Our reviewer says that the requested lab testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a female with a past history of superficial bladder cancer. This was treated with no recurrences since November 2015. CxBladder is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology, but there is lack of validation of clinical utility. 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 CxBladder Monitor panel have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Monitor testing panel provided on July 14, 2021.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided from February 1, 2021, to February 17, 2021.

You asked the Plan to pay for home health services. You say that this was billed with a correct Patient-Driven Groupings Model (PDGM) code. The Plan denied your request. The Plan says that this was billed with an invalid, incorrect, or missing Patient-Driven Groupings Model (PDGM) code.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that the claim at issue was billed with an invalid, incorrect, or missing Patient-Driven Groupings Model (PDGM) code. However, the Plan has not submitted any medical records used to determine the billed PDGM code was incorrect. The Plan has also not indicated any specific digits of the code are incorrect. The PDGM code billed on the claim is correctly formatted. Without additional information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for home health services provided from February 1, 2021, to February 17, 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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health aide or certified nurse assistant, per visit (T1012), and sanitation fee for a rental lift chair (A9270) provided from June 8, 2021, to July 6, 2021.

You asked the Plan to pay for the home health services. You say that you are your husband's caregiver. You say that you do your best with daily duties. You say that need help around the house. You also say that the cost of the home health aide is killing you. The Plan denied your request. The Plan says you do not have coverage for a personal care helper. The Plan also says that the sanitation fee for a rental lift chair is not a covered service.

The Plan must follow Medicare rules. The rules say that plans must pay for a medical service or item if regular Medicare would pay for it. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record shows that you chose transportation as your one supplemental benefit. Additionally, sanitation fee for a rental lift chair is not a coverable service. Therefore, we decided that the Plan does not have to pay for the home health aide or certified nurse assistant, per visit (T1012), and sanitation fee for a rental lift chair (A9270) provided from June 8, 2021, to July 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion administration services provided on May 19, 2021, billed with code 99601.
You asked the Plan to pay for the services as billed. You say that this is medically necessary treatment and should be covered. The Plan denied your request. The Plan says the code used is not valid for Medicare billing.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99601 has a status indicator of "I" on the Physician Fee Schedule. This means that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion administration services provided on May 19, 2021, billed with code 99601
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 28, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted by Medicare rules). 

You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 specialist office visit provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), cone beam computed 
tomography (CT) (D0364), and pulp vitality test (D0460) provided on August 9, 2021.

You asked the Plan to pay for the dental services. You say that you had approval to go out of network. You 
also say that you were under the impression that the dentist office worked with your insurance and that the 
services would be covered. The Plan denied your request. The Plan says the limited oral evaluation, cone beam 
CT, and pulp vitality test are not listed as 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, the limited oral evaluation, cone beam 
CT, and pulp vitality test are not among those covered under this benefit, regardless of the provider's network 
status. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), cone 
beam computed tomography (CT) (D0364), and pulp vitality test (D0460) provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on May 7, 2021.
You asked the Plan to pay for FoundationOne testing. 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 genetic testing procedures submitted under code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The testing at issue is not covered because it is not medically necessary. Based on this information, we decided that Medicare rules for coverage of FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for FoundationOne testing (81455) provided on May 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ER visit provided on October 8, 2020.
You asked the Plan to pay for the ER visit. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 ER visit provided on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel provided on April 5, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code is excluded by Medicare.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel provided on April 5, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 21, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 21, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on July 8, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified and a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes A4550 (surgical trays), A4556 (electrodes, pair), A4557 (lead wires, pair), 99072 (additional supplies, material, and clinical staff time), A4649 (surgical supply, miscellaneous) and A4253 (blood glucose test strips) have a status indicator of B and no separate
Medicare payment. Codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and fundus photography provided on June 4, 2019.
You asked the Plan to pay for the office visit and fundus photography. You say that due to a technical problem the claim was locked in the system and not submitted within the timely filing limit. You say that the unreliability of technology was beyond your control and the claim should be reconsidered. The Plan denied your request. The Plan says the claim was filed beyond the applicable timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the office visit and fundus photography was not filed until September 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the office visit and fundus photography provided on June 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 5, 2021.
You asked the Plan to pay for lab tests. You say that the enrollee's treating physician regarded this testing as medically necessary. 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 submitted 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 lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 7, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says members must
receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be
provided with an in-network provider.
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
physician's services. 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 physician's services provided on September 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (K0553) provided on June 11, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the supplies are not related to the enrollee's hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (K0553) provided on June 11, 2021.