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

We decided that the Plan does not have to pay an additional amount for vision hardware provided on September 18, 2020.
You asked the Plan to pay an additional amount for vision hardware. You say that the only check you have received was for $28. The Plan denied your request. The Plan says that the Plan received a claim for eyeglasses you purchased on November 19, 2020, in which the Plan reimbursed $122 to the provider.
You then submitted a claim for reimbursement for the eyeglasses you purchased on September 18, 2020, in which the Plan reimbursed you the remaining $28 of your $150 maximum calendar year benefit for vision hardware. Based on both of these claims that were filed, you have met your $150 maximum reimbursement for vision hardware for 2020. Therefore, no additional payment will be issued.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that you have met your $150 maximum reimbursement for vision hardware for 2020. Therefore, we decided that the Plan does not have to pay an additional amount for vision hardware provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on March 1, 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 codes 97032 and J3490 are 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 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The definition of code J3490 is unclassified drugs. 

We find that CPT codes 97032 and J3490 are not supported in the medical record. Specifically, there is no documentation of electrical stimulation to support code 97032. There is no documentation of an injection of unclassified drugs on J3490. 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 services rendered on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on March 12, 2021.
You asked the Plan to pay for the vision services. You say that you have never needed to have a primary care
physician refer you to an eye doctor. The Plan denied your request. The Plan says you must receive care from
in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the
plan's service area or if the care cannot be provided with an in-network provider, which requires prior
authorization from the Plan.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit
that exceeds Medicare coverage.
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.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. The Plan did not pre-approve the vision 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 vision services provided on
March 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the breast.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary, as there is a strong
history of breast cancer on both sides of the family. The Plan denied your request. The Plan says there is no
personal history of breast cancer.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found per the guidelines, this
would be approved if you were BRCA +, had an inherited disorder, and had a lifetime risk of 20-25%. As your
lifetime risk is 18%, this will be denied as not 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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI of the breast.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.

You asked the Plan to pre-approve the compression stockings. You say that the compression garments have been covered previously and due to the cost of the compression stockings, you need assistance to cover the costs. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation, problem focused (D0140) intraoral periapical, first film (D0220) intraoral periapical, each additional film (D0230) sales tax (D9985) extraction, erupted tooth or exposed root (D7140) provided on March 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the dental services. You say that you went to Hawaii and had to go to the dentist and had a tooth pulled. This was an emergency extraction. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 limited oral evaluation, problem focused (D0140) intraoral periapical, first film (D0220) intraoral periapical, each additional film (D0230) sales tax (D9985) extraction, erupted tooth or exposed root (D7140) provided on March 21, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, abdomen (74018) provided January 3, 2021.

You asked the Plan to pay for the diagnostic services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this is a duplicate of another claim that has already been processed.

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 74018 is radiologic examination, abdomen. 

We find that CPT code 74018 is not supported in the medical record. Specifically, two separate claims were submitted by the same provider. Payment for this CPT code was processed on check dated June 16, 2021. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, abdomen (74018) provided January 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the propofol injection coded J2704 provided on January 26, 2021.

You asked the Plan to pay for the propofol injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 J2704 is injection, propofol, 10 mg.

We find that CPT code J2704 is not supported in the medical record. Specifically, the submitted medical records do not support the code billed, the modifier billed, or the units billed. Based on this information, we decided that Medicare rules for coverage of the propofol injection have not been met. Therefore, we decided that the Plan does not have to pay for the propofol injection coded J2704 provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 21, 2021.

You asked the Plan to pay for lab test. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because predictive screening testing is not a Medicare benefit.

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. 

The test at issue in this appeal, lab test, was requested for screening purposes. Medicare does not cover this test for screening purposes. Test code 0202U is not one of the codes selected by Medicare for coverage of COVID-19 testing. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313, E2377).

You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 accessories. 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 you meet criteria for coverage of the requested expandable controller (E2377) and expandable controller harness (E2313). As there is only one approved power option on this wheelchair (power tilt), the requested accessories are not allowed. 

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2313, E2377).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on February 5, 2021.

You asked the Plan to pay for the emergency department visit (99284). You say that the Plan should pay this claim. The Plan denied your request. The Plan says they did not receive the primary payer'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 has indicated in the decision letter to the provider that it is their responsibility to bill the primary insurer before submitting the claim to the Plan. As the secondary insurer, the Plan cannot be held responsible for the emergency department visit (99284) until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021.

You asked the Plan to pay for the laboratory services. 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. 

The codes at issue are not payable on the Physician Fee Schedule because they have a PC/TC indicator of "9" meaning that the concept of professional/technical components does not apply. These services are paid in the Clinical Laboratory Fee Schedule and only have a fee for the global service, and no breakdown for PC/TC of the service. This means that payment cannot be made for these codes when billed with the modifier -26. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.

Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) lenses, bifocals (V2200) miscellaneous, vision item or service (V2799) purchased February 12, 2021.

You asked the Plan to pay for the vision services. You say that you would like or the Plan to reimburse you the $150 that you spent for your glasses. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to routine contact lenses or eyewear every 2 years. The records show you last received this on April 19, 2019. Therefore, the benefit was not available on the date of service. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) lenses, bifocals (V2200) miscellaneous, vision item or service (V2799) purchased February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified oral surgery procedure (D7999) provided March 8, 2021.
You asked the Plan to pay for the dental services. You say that you were told the provider couldn't bill as an extraction, so the billed as miscellaneous dental service. The Plan denied your request. The Plan says this service is not covered under the Plan 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. Page 4-70 of the EOC says any service not listed are not covered. This service is not listed as a covered dental service. 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 unspecified oral surgery procedure (D7999) provided March 8, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 11, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is not supported in the medical record. Specifically, 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, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 11, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74178).

You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

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 of the abdomen and pelvis. Our reviewer says that the services are medically necessary. Our physician reviewer found the presence of microscopic hematuria, 4-10 RBC/HPF mandates investigation for urinary tract stones and importantly occult malignancy. As such, a CT urogram is the procedure of choice and should be approved.

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 of the abdomen and pelvis have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74178). 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a cardiac catheter placement procedure (93460) provided on March 15, 2021.
You asked the Plan to waive the coinsurance for a catheter placement procedure. You say that prior to your procedure, you were quoted a copayment of $700. You also say that you are disputing the implants shown on the bill as you did not require a stent. The Plan denied your request. The Plan says the copayment you are being charged is correct. The Plan also says that the current procedural terminology (CPT) codes show no stent insertion.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare-covered surgery or services at an outpatient hospital or ambulatory surgical center,
including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a 20% coinsurance for a catheter placement procedure. The allowed amount of the
claim is $6,023.36, resulting in a coinsurance obligation of $1,204.67 ($6,023.36 x 20% = $1,204.67). You
have been asked to pay a coinsurance of $1,112.47, which is less than the Plan's contracted amount. A catheter
placement procedure falls within the outpatient facilities and ambulatory surgical centers 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 coinsurance for a cardiac catheter placement procedure (93460) provided
on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vasopneumatic device therapy procedure and subcutaneous
injection provided on August 3, 2020.

You asked the Plan to pay for vasopneumatic device therapy procedure and subcutaneous injection.. You say
that the enrollee needed the procedures because of intense cramping in legs and feet overnight. The Plan denied
your request. The Plan says there is no documentation noting the presence of edema.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. The device is to reduce edema or lymphedema, treatment of
peripheral neuropathy with this device is not considered medically reasonable and necessary. Based on this
information, we decided that Medicare rules for coverage of vasopneumatic device therapy procedure and
subcutaneous injection. have not been met. Therefore, we decided that the Plan does not have to pay for
vasopneumatic device therapy procedure and subcutaneous injection provided on August 3, 2020.