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

We decided that the Plan does not have to pay for the diagnostic testing services (95938, 95908, 95886, 95940, A4215, A4556) provided on June 3, 2021.  You asked the Plan to pay for diagnostic services. You say that these services were medically necessary and pre-approved. This claim was processed incorrectly, and payment for these services should be made separately. The Plan denied your request. The Plan says that the provider type submitted on this claim is not found on the Medicare Provider/Supplier to Healthcare Provider Taxonomy Crosswalk, and therefore is not eligible to receive Medicare payment. The provider in question is not a recognized facility or legally qualified physician, and billing agents and third-party vendors do not fall within the category of eligible providers, these services are not payable under the Plan.    In addition, records indicate that these services were provided for another physician and/or facility, and not at the request of the enrollee. It is suggested that you contact the physician and/or facility for any reimbursement. This claim has been paid under a separate claim as submitted by the facility/hospital provider as part of the Inpatient Prospective Payment System (PPS).  The Plan must follow Medicare rules. Medicare rules say that Medicare pays for inpatient hospital services under the Inpatient Prospective Payment System (PPS). These amounts are, with certain exceptions, payment in full to the hospital for inpatient operating costs. All items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. This provision applies to all hospitals, regardless of whether they are subject to PPS. Medicare rules also say that no Medicare payment can be made to a provider that is not enrolled in the Medicare program.  We looked at the file and Medicare rules. The provider in this case is not eligible to enroll in the Medicare program and bill directly. In addition, the services at issue were performed during an inpatient spinal surgery. Medicare pays for inpatient services through the prospective payment system (PPS) using Diagnosis Related Groups (DRGs). The payment to the facility is for all items and non-physician services rendered to an inpatient during their stay. Since these services are items/non-physician services, payment for them is made to the facility. Based on this information, we decided that Medicare rules for coverage of diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic testing services (95938, 95908, 95886, 95940, A4215, A4556) provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitoring (CGM) supplies rendered on July 10, 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 there is no valid physician order.  The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any durable medical equipment (DME) item to a beneficiary.  We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitoring (CGM) supplies rendered on July 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapy services (97110) provided December 18, 2020.  You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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 CPT code 97110 is not supported in the medical record. Specifically, the records show this service was performed by a therapy assistant in the home setting. There is a more appropriate CPT code for this service (G0157). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient hospital care provided on July 19, 2021.  You asked the Plan to waive the deductible for inpatient hospital care. You say that you were inpatient and the deductible for inpatient hospital care is only $50 not $150. 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. Your contract with the Plan says that there is a $150 deductible which applies to inpatient hospital care.   You received inpatient hospital care on July 19, 2021. The record shows that you had paid $0 toward the $150 deductible prior to receiving the services. Therefore, you are responsible to pay the $150 deductible.   The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time inpatient hospital care was received on July 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for inpatient hospital care provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for gingival irrigation per quadrant (D4921) and periodontal scaling and root planing, four or more teeth, per quadrant (D4341) provided on August 24, 2021, to August 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for gingival irrigation per quadrant and periodontal scaling and root planing. You say that the sales department lied about what is covered under the Plan. You are requesting reconsideration of this claim. The Plan denied your request. The Plan says the services are not covered under your benefit plan. The Plan also reviewed and verified that there is no call history of you contacting the plan to verify dental benefits.  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. Therefore, we decided that the Plan does not have to pay for gingival irrigation per quadrant (D4921) and periodontal scaling and root planing, four or more teeth, per quadrant (D4341) provided on August 24, 2021, to August 26, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on March 2, 2021. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  The file shows that CPT code 11042 was billed along with 11765. We find that CPT code 11042 may be eligible for payment when billed with this code pair. The claim information does not show that the code was billed with a modifier suitable for payment. 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 debridement services provided on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Genesight testing (81479) provided on February 3, 2021.  You asked the Plan to pay for Genesight 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 in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician.   We looked at the file and Medicare rules. The physician order in the file is not signed. Based on this information, we decided that Medicare rules for coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on July 8, 202.  You asked the Plan to pay for the testing services. You say that the specimen was collected at the referring physician's office. The Plan denied your request. The Plan says the billed code cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records do not show that the specimen at issue was obtained in an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 8, 202.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve osteogenesis stimulator (CPT code E0748).  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  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 DME. Our physician reviewer found the criteria for bone stimulator not met. There is only one level of spinal fusion performed at L4-5. Not enough levels of fusion present.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve osteogenesis stimulator (CPT code E0748).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a single bitewing x-ray (D0270), an intraoral periapical first radiographic image (D0220), inhalation of nitrous oxide (D9230) and a tooth extraction (D7140) provided on February 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for dental services. You say that this was an emergency visit due to an infection. There was a snowstorm, and you could not cross the bay. You also say this was the only dentist available. The Plan denied your request. The Plan says services provided by an OON provider are not covered under this benefit 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. The Plan covers dental services when you receive services from a network dental provider.   We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Specifically, the services were rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for a single bitewing x-ray (D0270), an intraoral periapical first radiographic image (D0220), inhalation of nitrous oxide (D9230) and a tooth extraction (D7140) provided on February 6, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure) (77063) provided August 9, 2021. You asked the Plan to pay for the screening mammography. You say that your doctor died, and his assistant opened another office. Another doctor took over that office but couldn't get your records, so she sent you to get a mammogram. The Plan denied your request. The Plan says the service is a covered benefit however this service exceeds the maximum benefit limitation.  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. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  In this case, the service at issue is a covered benefit however this service exceeds the maximum benefit limitation. The Plan contract says that the Plan will cover one screening mammogram every 12 months for women aged 40 and older. The records show that this service was already processed and paid for date of service January 4, 2021. Therefore, the benefit was not available. Therefore, we decided that the Plan does not have to pay for screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure) (77063) provided August 9, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on August 5, 2021.  You asked the Plan to waive the copayment for emergency care. You say that you feel that the charges are too high for emergency care. 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 a $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient hospital services and pay for the self administered drugs provided on August 25, 2021, through August 30, 2021.  You asked the Plan to waive the copayment for the outpatient hospital services and pay for the self administered drugs. You say that you would like reconsideration because your income will not cover the costs of these services. The Plan denied your request. The Plan says the copayment and denial of the self administered drugs was applied appropriately.  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 $90 copayment for Emergency Care.   You have been asked to pay a $90 copayment for the self administered drugs. 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. Additionally, self administered drugs are not covered under Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital services and pay for the self administered drugs provided on August 25, 2021, through August 30, 2021.   Benefits for the self administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on March 5, 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 procedure code 99152 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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.  We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status. 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 moderate sedation services rendered on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  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 service. Our physician reviewer found the documented objective findings are also plausibly indicative of potential meniscal and/or other alternate pathology in the knee. There is no more advanced imaging to rule out other potential causes of pain and disability. Additionally, detailed documentation is not evident regarding lab work to rule out any active infections of the knee or systemic bacteremia, urinary tract infection, dental infection or active skin infection. Therefore, medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) (CPT code 27447), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that the use of the Intracept procedure is better than regular treatments.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy.   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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy.   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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2020.  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 separately payable.  The Plan must follow Medicare rules. Medicare rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the laboratory services were performed for end-stage renal disease (ESRD). Payment is included in the ESRD facility payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2020.