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

 We decided that the Plan does not have to pay for moderate sedation services (procedure code 99152) provided to the enrollee on June 14, 2021.  

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99152 remains 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 provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older."  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records.  

Our reviewer found the operative report does not include enough documentation to support a qualified healthcare professional performed moderate sedation monitoring. The provider monitored ""Continuous hemodynamic monitoring", however, the procedure is dictated by this same provider. In order to report CPT 99152 a independent trained observer is someone other than the performing provider.  

We looked at this coder'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 pay for moderate sedation services (procedure code 99152) provided to the enrollee on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 30, 2021.  

You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says there is no further benefit available to the enrollee since he utilized his full $75 allowance for non-Medicare covered eyeglasses at the time of services. The enrollee's Evidence of Coverage clearly states that he is responsible for any amount above the coverage limit.  

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 the Plan has paid the maximum eyewear allowance of $75 to the provider. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone marrow aspiration for local autograft for bone grafting during spine surgery.  You asked the Plan to pre-approve this surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says the lumbar surgery was approved; the bone marrow aspiration is not covered by Medicare.  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 this surgery. Our physician reviewer found there is insufficient evidence in the peer-reviewed medical literature to support the use of bone marrow aspiration for local autograft for bone grafting during spine surgery.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this surgery have not been met.   Therefore, we decided that the Plan does not have to pre-approve lumbar surgery and bone marrow aspiration for local autograft for bone grafting during spine surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for eyewear provided on April 15, 2021.  You asked the Plan to reimburse you for the eyewear. The Plan denied your request. The Plan says the eyewear was obtained from an out-of-network provider.  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 the eyewear was not provided by the Plan's vision network provider. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyewear provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the removal of a tunneled central venous catheter, without subcutaneous port or pump (36589) provided on September 16, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $200 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.    You have been asked to pay a $200 copayment for the outpatient surgery provided at an outpatient hospital facility. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the removal of a tunneled central venous catheter, without subcutaneous port or pump (36589) provided on September 16, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ambulance service, basic life support, non-emergency transport (A0428, and ground mileage (A0425) provided on August 5, 2021.  You asked the Plan to pay for the transportation services. You say that the enrollee did not have any coverage at the time the transport was provided. The Plan denied your request. The Plan says that the claim was processed correctly.  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 documentation provided shows that the enrollee's coverage ended prior to the date of service. The record also shows that the enrollee does not have a different primary insurance carrier. Therefore, we decided that the Plan has to pay for the ambulance service, basic life support, non-emergency transport (A0428, and ground mileage (A0425) provided on August 5, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided August 3, 2021.  

You asked the Plan to pay for the dental services. You say that you need to have these procedures covered under your $325 annual allowance. The Plan denied your request. The Plan says this service is not covered under the Plan benefits. Prior approval is required from the Plan for Medicare covered dental 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.  We looked at the file and Medicare rules. The file shows that procedure codes 88361, 88305, and 88312 were billed with the -26 modifier. The PC and TC of the services were not performed in a different payment locality; therefore, the use of modifier -26 is not appropriate.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 95869 (needle electromyography, thoracic paraspinal muscles) and 95861 (needle electromyography, 2 extremities). Code 95869 is a column II code with a modifier indicator of 1 when billed with column I code 95861. Code 95869 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the WATS3D testing provided on June 1, 2021.  You asked the Plan to pay for the WATS3D testing. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.  The enrollee was referred for the WATS3D testing by a contract provider. The file does not show that the plan provided notice that the WATS3D testing would not be covered. Under Medicare rules, this means the WATS3D testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the WATS3D testing provided on June 1, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental extractions, surgery and sedation provided on  April 14, 2021.  You asked the Plan to pay for these services. You say that these dental services should be covered by the Plan. The Plan denied your request. The Plan says while extractions 3,5,11 and 12 were paid, the denial is upheld for teeth 4,6,7,9,23 and 24. The information sent by your dentist shows that the tooth removal is not as bad as what your dentist says. Also, D9219 Evaluation for deep sedation and general anesthesia, D9612 drug injection for 2 or more were denied as these services are not covered under your benefit plan. Codes D9222 and D9223 for general anesthesia 120 minutes are denied because your dentist does not have the permit needed to provide this type of anesthesia treatment. Finally, code D7310 oral surgery procedure trim bone with extraction x2 was covered due to a lack of dental records to support these services were 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 these services. Our physician reviewer found code D7210 code was not appropriate used for the denied tooth numbers because they were not broken down to a point that there would be a necessary cutting of the supporting bone in order to remove these teeth. The operative report states all teeth were removed with elevation and forceps, with no documentation of any surgical procedures being performed. The extractions under codes D7210 are not supported by the record. 21. The documentation indicates that the insurer does not have verification of certification of the provider to administer sedation anesthesia. The provider's web site indicates that this dentist is a dual degreed Oral and Maxillofacial Surgeon. Given the nature of the procedures often performed by oral surgeons, it would be highly unlikely that the required anesthesia permits would not be properly in place.  Given that the provider is not in the insurer's network, the verification of such permits has not been submitted to the insurer but can be obtained from the provider if needed.  Given the provided documentation cannot be verified at this time that the anesthesia permits are properly held, these services cannot be covered.   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 denied services have not been met. Therefore, we decided that the Plan does not have to pay for dental extractions, surgery and sedation provided on April 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services rendered on June 9, 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 a clinical psychologist must have a referral and consult from the beneficiary's primary care physician (PCP). 

We looked at the file and Medicare rules. There is no documentation of a referral and consult from the enrollee's PCP. 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 psychotherapy services rendered on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services rendered on August 16, 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 provider has opted out of Medicare.  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 supplemental dental benefits from any licensed dental provider who accepts Medicare in the United States.   We looked at the file and the Plan's rules. The file shows that the provider has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services rendered on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection of a major joint or bursa (20611) provided on October 22, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  

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 $35 copayment per provider, per day for each  in-network Medicare-covered specialist visit. Covered services include medically necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. Coverage includes consultation, diagnosis, and treatment by a specialist.  

You have been asked to pay a $35 copayment for the Medicare-covered specialist visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection of a major joint or bursa (20611) provided on October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the microfluid analysis rendered on November 3, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 83861 is 2. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. 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 microfluid analysis rendered on November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on June 25, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the record indicates that the enrollee has adenocarcinoma of the colon. The record does not contain primary source medical documentation to satisfy the coverage criteria. The provided records do not indicate that the enrollee is seeking further treatment or that he has not previously undergone testing. The testing was therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral exam (D0140) provided October 5, 2021.

You asked the Plan to pay for the limited oral exam. You say that the services were medically necessary. The Plan denied your request. The Plan says the benefit for this service was exhausted when the service was 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 plan only covers one limited oral evaluation per year. The records show this service was previously provided on May 7, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral exam (D0140) provided October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for debridement services (11042) provided on July 23, 2021, and August 6, 2021.  

You asked the Plan to waive the copayment for the debridement services. You say that the cost-sharing applied correctly based on the services provided. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.   

You have been asked to pay a $590 copayment for debridement services. Debridement services fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The record indicates that these services were performed in an outpatient setting. 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 debridement services (11042) provided on July 23, 2021, and August 6, 2021.