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

We decided that the Plan does not have to pay more for the complete mandibular denture (D5120) provided on
April 5, 2021.
You asked the Plan to pay more for the complete mandibular denture. You say that you were advised that this
provider was in-network. You also say that you did not find out until later that the treating provider was out-ofnetwork,
and their contract had expired. The Plan denied your request. The Plan says this service was rendered
by an out-of-network provider. The Plan also says that a one-time exception was made, and more was paid for
this claim due to a misunderstanding of the treating provider being in-network.
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 Plan offers an annual maximum
dental benefit of $1,000. The record shows that you met the annual maximum benefit while processing this
claim for the April 5, 2021, date of service and your annual maximum benefit has been exhausted. Therefore,
we decided that the Plan does not have to pay more for the complete mandibular denture (D5120) provided on
April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on April 6, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show what kind of precautions were taken prior to treating the patient and the code should be reprocessed for prompt payment. The Plan denied your request. The Plan says payment for this service is bundled and not eligible for separate reimbursement.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.
You asked the Plan to pre-approve compression stockings. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code [enter HCPCS code] are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on March 30, 2021.
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your request. The Plan says they did an outreach with the ordering provider and left a voicemail to confirm the order for genetic testing. The Plan states there was no response from the referring provider; hence, the result is that the initial denial is upheld.
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 genetic testing have not been met.
There is no verification that the ordering provider on the documentation provided actually ordered the genetic testing. Therefore, we decided that the Plan does not have to pay for the genetic testing provided to the enrollee on March 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Decitabine 50 mg vial (J0894).
You asked the Plan to pre-approve Decitabine. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Decitabine have not been met. Specifically, there were no medical records provided in this case. We requested additional medical records but did not receive any in response. Without the medical records, we cannot review to see if the services were medically necessary. Therefore, we decided that the Plan does not have to pre-approve Decitabine 50 mg vial (J0894).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening test (CPT code(s): 83520, 88346, 88350,
83516, 86332, 86353, 88185, 86356, 88184, 88230, 88240, 88241) provided to the enrollee on March 3, 2021.
You asked the Plan to pay for the screening test. You say that the claim should be paid. The Plan denied your
request. The Plan says this 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, the screening test, was requested solely for screening purposes. Medicare does
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
the screening test (CPT code(s): 83520, 88346, 88350, 83516, 86332, 86353, 88185, 86356, 88184, 88230,
88240, 88241) provided to the enrollee on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) provided on January 12, 2021.
You asked the Plan to pay for the denture. You say that this service was necessary, and you believed it would be covered. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
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 the complete upper denture (D5110) provided on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 4, 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 testing is not covered.
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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 4, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient evaluation by an anesthesiologist provided on April 29, 2021.
You asked the Plan to pay for the inpatient evaluation. You say that this is a payable service. The Plan denied your request. The Plan says that pre and post-anesthesia evaluations are included in the anesthesia care package. Therefore, this evaluation is not separately payable.
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 not provided evidence of payment for operative anesthesia services into which this evaluation would be bundled. The records provided show that this evaluation was done one day after surgery and was ordered by the surgeon due to postoperative pain. This would not be considered to be a post-anesthesia assessment that is included with payment for the anesthesia service. As this appears to have been provided the day after the surgery, a modifier would also not be required. Therefore, we decided that the Plan has to pay for the inpatient evaluation by an anesthesiologist provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you cannot shower without the chair. The Plan denied your request. The Plan says this is not a covered item according to Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on April 13, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that the testing must be ordered by a physician
who is treating the member.
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. Specifically, the record includes a physician order. There is no evidence that this
physician is not treating the member. There is no indication that the Plan has reached out to the provider to
determine if they are treating the member. It is the burden of the Health Plan to substantiate their denial with
evidence. This denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan
has to pay for the laboratory services provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
April 23, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the
enrollee on April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88305 and 88312) provided to the enrollee on March 25, 2021, by an out-of-network provider.
You asked the Plan to pay for the laboratory services. You say that the doctor's office failed to send in a preauthorization form for approval. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88305 and 88312) provided to the enrollee on March 25, 2021, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 5, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
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 medical services provided to the enrollee on January 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared light therapy provided from January 12, 2021, through February 10, 2021.
You asked the Plan to pay for infrared light therapy. You say that the infrared light therapy is medically necessary. The Plan denied your request. The Plan says the infrared light therapy 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 pay for infrared light therapy. Our reviewer says that
the requested infrared light therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found that infrared therapy devices are used to treat an area of the skin and adjacent subcutaneous tissues of a patient with infrared therapy energy, using an array of juxtaposed infrared diodes affixed to a flexible pad to retain skin contact. The devices can also produce local warming, though this may be a secondary effect. The use of infrared therapy devices has been proposed for a variety of disorders. A wide variety of devices are currently available. Medicare has determined that there is insufficient evidence to conclude the use of infrared therapy devices and any related accessories is reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of infrared light therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared light therapy provided from January 12, 2021, through February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging, breast, without and/or with contrast material (77049) provided February 9, 2021.
You asked the Plan to pay for the diagnostic services. You say that please review attached Medicare rate sheet to support claim reimbursement rate of 20.9% of billed charges per Medicare fee schedule. The Plan denied your request. The Plan says outpatient code editor (OCE) 62 code not recognized, use alternate code. Please correct OCE edit error on other clam line.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we find that CPT code 77049 is not supported in the medical record. Specifically, CPT code 77049 was billed on an outpatient hospital claim with type of bill code 131. Per the Outpatient Prospect Payment System (OPPS), CPT code 77049 has a status indicator of B. This means that CPT code 77049 is not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). An alternate code that is recognized by OPPS may be available. 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 magnetic resonance imaging, breast, without and/or with contrast material (77049) provided February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on March 8, 2021.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. 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 drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on February 15, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular disease screening provided on October 15, 2020.
You asked the Plan to pay for the cardiovascular disease screening. You say that you would like reconsideration because this testing was medically necessary and billed correctly. The Plan denied your request. The Plan says Medicare does not pay for cardiovascular risk assessment testing except for the basic lipid panel.
The Plan must follow Medicare rules. Medicare rules say that line items for billing cardiovascular disease screening shall contain 80061, 82465, 83718 or 84478.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular disease screening have not been met. Specifically, the cardiovascular disease screening was not billed with the required CPT codes. Therefore, we decided that the Plan does not have to pay for the cardiovascular disease screening provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physicians services provided to the enrollee
on June 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physicians services provided to the
enrollee on June 9, 2021.