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

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis
(D1110) provided on June 17, 2021, by a Medicare opt-out provider.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have been doing
dental business with this local dental school for years and have been reimbursed by the Plan for the last two
years. The Plan denied your request. The Plan says you received these services from a provider who chose not
to receive Medicare funds. The Plan also says that you did not contact the Plan in regard to your cost share or
provider questions prior to receiving these 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 requested items or services are not
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the
Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on June
17, 2021, by a Medicare opt-out provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on December 4, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and the rules. We find that CPT codes 99100 and 99140 are bundled codes. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on December 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physical therapy services provided from
April 16, 2021, to May 7, 2021.
You asked the Plan to waive the deductible for the physical therapy services. You say that the services should
be covered as you were unaware of the charges beforehand and were under the impression that it would only be
a $20 copayment per visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based
on the services provided.
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 $750 deductible which applies to outpatient rehabilitation services,
specifically physical therapy services.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to Outpatient rehabilitation services. The record indicates that you met this deductible after May 13th, 2021, which would be after the services rendered on May 7th, 2021, any charges before this were subject to cost-sharing. This cost sharing is a contractual obligation that had not been met at the time the physical therapy services were received on April 16, 2021, to May 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy services provided from April 16, 2021, to May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine provided on August 30, 2021.
You asked the Plan to pay for this vaccine under Medicare Part B. You say that your doctor told you that you needed this vaccine. The Plan denied your request. The Plan says preventative Tdap vaccines are not covered under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under Medicare Part B. The Plan follows the same rules. The records show this was given as a preventative vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine provided on August 30, 2021 under the Medicare Part B benefit. Please submit your request for payment of this vaccine to your Medicare Part D carrier
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided to the enrollee on
August 4, 2021.
You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not covered as billed.
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 chest x-ray have not been met. Our records indicate a National
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 36573 and 71045. This
PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however,
an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does
not have to pay for the chest x-ray (CPT code 71045) provided to the enrollee on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on March 4, 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. We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facial physical therapy (97161, 97162, 97163, 97110, 97112, 97116, 97140, 97750 x 14 units each) to be provided at a tertiary level of care by an out-of-network (OON) provider.
You asked the Plan to pre-approve facial physical therapy. You say that you would like to see the requested provider because there is no network physical therapist has an expertise in Bell's Palsy The Plan denied your request. The Plan says the services can be performed in-network at a non-tertiary level of care.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The provider at issue in this case is not a network provider with the Plan. 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 facial physical therapy. Our reviewer says that the facial physical therapy can be provided at a lower level of care. Our physician reviewer found that based on the medical records provided to this reviewer there is no documentation that the out-of-network therapy meets Medicare criteria for medically necessary (as opposed to in-network therapy). Available records do not document that the in-network therapy provider would be unable to provide a comparable level of care for the enrollee's condition. Based on the medical records provided to this reviewer there is no documentation that the in-network therapy provider would be unable to provide a comparable level of care for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facial physical therapy have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve facial physical therapy. Medicare rules for coverage of facial physical therapy to be provided by the requested facility have not been met. Therefore, we decided that the Plan does not have to pre-approve facial physical therapy (97161, 97162, 97163, 97110, 97112, 97116, 97140, 97750 x 14 units each) to be provided at a tertiary level of care by an out-of-network (OON) provider
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve prostate Next Generation Sequencing fusion panel testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary in order to identify any actionable genetic alterations. The Plan denied your request. The Plan says that this testing is considered investigational.
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found tumor molecular and biomarker analysis may be used for treatment decision-making, including understanding eligibility for biomarker-directed treatments, genetic counseling, early use of platinum chemotherapy, and eligibility for clinical trials. Clinical trials may include established and/or candidate molecular biomarkers for eligibility. Tumor molecular profiles may change with subsequent treatments and re-evaluation may be considered at time of cancer progression for treatment decision-making. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have been met. Therefore, we decided that the Plan has to pre-approve prostate Next Generation Sequencing fusion panel testing for the enrollee.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the enrollee on August 4, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
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 abdominal ultrasound have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (CPT code 76705) provided to the enrollee on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on July 26, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
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 CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot, ankle feature, and other parts for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says incorrect codes are used for Freedom Agilix foot.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that K5986 and K5987 are the correct codes for the device (the Freedom Agilix foot) requested in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg with an advanced foot, ankle feature, and other parts for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Durolane. Our reviewer says that Durolane (J7318) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the patient has not tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on July 13, 2021.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
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 office visit have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 99213 and 99183. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99213) provided to the enrollee on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified (CPT code 00300) provided to the enrollee on July 30, 2020.
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 enrollee has a primary insurance, and the Plan needs the primary carrier's Explanation of Benefits.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan needs the primary carrier's Explanation of Benefits. As the secondary insurer, the Plan cannot be held responsible for the service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified (CPT code 00300) provided to the enrollee on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640) provided to the enrollee on August 17, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 laboratory services have not been met. CPT code(s): 87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a nursing facility POS 32. Also, the laboratory results submitted indicate the specimen was collected on August 17, 2020, and received by the lab on August 19, 2020. Of note, the enrollee resides in Georgia (GA) and the billing laboratory is located in Texas (TX); therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640) provided to the enrollee on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive ophthalmological examination provided on August 24, 2021.
You asked the Plan to waive the copayment for an eye exam. You say that you believed you received a routine eye exam and should not have a copayment. You say you were told you would have no copayment as long as it was a routine visit. You also say no one had told you routine eye exams are only free of charge is it is performed by an optometrist. The Plan denied your request. The Plan says the copayment was applied correctly for a diagnostic eye exam. The Plan says the medical records were reviewed which indicated the eye exam was performed by an ophthalmologist who provided a medical diagnosis of macular drusen.
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 $25 copayment for Vision Care.
You have been asked to pay a $25 copayment for an eye exam. Eye exams fall within the Vision Care benefit category. The Plan contract states a $25 copayment is applied to Medicare-covered eye exams performed to diagnose and treat diseases of the eye. 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 a comprehensive ophthalmological examination provided on August 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic laboratory services (CPT code(s): 82607, 80069, 82728, 83540) provided to the enrollee on May 13, 2020.
You asked the Plan to pay for the diagnostic laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says a corrected claim must be received within one year (12 months) from the processed date of the original claim submission.
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 original claim 820201690079554 has a processed date of June 30, 2020, and this corrected claim was received on August 5, 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 diagnostic laboratory services (CPT code(s): 82607, 80069, 82728, 83540) provided to the enrollee on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 15, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
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 CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 15, 2021.