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

We decided that the Plan does not have to pay for the laboratory services provided on July 6, 2021.

You asked the Plan to pay for the laboratory services. You say that you are an independent laboratory and do not see patients directly. You say that the records support the claim is not hospice related and the claim should be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 the laboratory services provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for morphometric analysis, in situ hybridization (CPT code 88374 (3 units)) provided to the enrollee on March 1, 2021.
You asked the Plan to pay for the services. You say that your expertise and specialized testing was crucial to treating the enrollee's complex medical condition. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The Correct Coding Initiative (CCI) dictates the number of times (units) a specific code can be provided within a set time period. This is a called the Medically Unlikely Edit or MUE. The MUE for CPT 88374 is 5 units within 3 dates of service. When a provider bills a service that exceeds the MUE, we process the service to allow up to the Maximum number of units and deny the units that exceed the MUE. Modifier 91 does not override the MUE. There is no modifier that will override the MUE. Therefore, we decided that the Plan does not have to pay for morphometric analysis, in situ hybridization (CPT code 88374 (3 units)) provided to the enrollee on March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110) and a topical application of fluoride (D1208) provided on May 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a periodic oral evaluation, prophylaxis and a topical application of fluoride. You say that you are requesting reconsideration of payment for the dental services provided to the enrollee. The Plan denied your request. The Plan says there is no coverage for services rendered by an OON provider.
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 a periodic oral evaluation, prophylaxis and a topical application of fluoride when the services are rendered by an in-network provider.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, prophylaxis and a topical application of fluoride have not been met. The EOC confirms you must receive dental services from an in-network provider. Specifically, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110) and a topical application of fluoride (D1208) provided on May 19, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 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 genicular nerve radiofrequency ablation is still being studied for efficacy in the treatment of knee pain due to osteoarthritis or in the setting of replacing or significantly deferring total knee arthroplasty (TKA).
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 genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve radiofrequency ablation of the right knee is not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on July 16, 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 physician services provided to the enrollee on July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are asking for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ankle foot orthosis (CPT code L1971NU) and addition to lower extremity orthosis, soft interface for molded plastic, below knee section (CPT code L2820NU) provided on August 24, 2021.

You asked the Plan to waive the coinsurance for the DME. You say that the doctor told you that the insurance does not pay for the orthopedic inserts, and you told him that you did not care, and you were going to pay for them out of pocket. You state the doctor told you they had something better than the inserts and it was the medical boot. You state you told the doctor you did not want that, and he told you to try it out and it did not work. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file shows that you received the DME on August 24, 2021. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $552.06 The total you owe is $110.41 ($552.06 x 20% = $110.41). 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 the ankle foot orthosis (CPT code L1971NU) and addition to lower extremity orthosis, soft interface for molded plastic, below knee section (CPT code L2820NU) provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health telehealth visit you had on August 17, 2021.

You asked the Plan to waive the copayment for the outpatient mental health telehealth visit. You say that you were told by the provider and by the Plan that this copayment would be waived. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they have phone records showing that you called them to ask about copayments being waived on August 2, 2021. On that date, you were advised that the copayment waiver ended on March 31, 2021.

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 $30 copayment for outpatient mental health visits.

You have been asked to pay a $30 copayment for the outpatient mental health telehealth visit. the outpatient mental health telehealth visit falls within the outpatient mental health visits benefit category. There is no provision in your contract for a waiver of this amount. 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 outpatient mental health telehealth visit you had on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on March
22, 2021.
You asked the Plan to pay for code 99153. 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.
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided
represent professional charges; however, procedure code 99153 was provided in a facility with a place of
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical
Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation
services (99153) provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code S2900 billed for date of service November 2, 2020.  You asked the Plan to pay for procedure code S2900. You say that you have provided records to substantiate payment. The Plan denied your request. The Plan says this code is not payable. The Plan must follow Medicare rules.         Medicare rules say that that codes with a status indicator of E1 are not paid by Medicare when submitted on any outpatient claims. Procedure code S2900 has a status indicator of E1. Therefore, we decided that the Plan does not have to pay for procedure code S2900 billed for date of service November 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Rhythm ECG (93042) provided on May 10, 2021.  You asked the Plan to pay for code 93042. 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. In this case, we have confirmed that code 93042 is a column II code to column I code 12002. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Rhythm ECG (93042) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ankle-brachial index tests to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve ankle-brachial index testing. You say that it would be easier to get the services from the provider you requested. The Plan denied your request. The Plan says the requested test is a simple outpatient test which can be performed by an in-network provider.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve ankle-brachial index tests to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (84439, 84481, 82728, 82306, 82607, 82746, 83036, 84144, 84681, 82977, 83525, 86703, 82670, 83001, 83002, 82533, 83540, 84403, 80074, 83970, 82610 84466, 84443) provided June 3, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services were for screening purposes only and are non-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 lab services at issue in this appeal were 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 lab services (84439, 84481, 82728, 82306, 82607, 82746, 83036, 84144, 84681, 82977, 83525, 86703, 82670, 83001, 83002, 82533, 83540, 84403, 80074, 83970, 82610 84466, 84443) provided June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 18, 2021.  You asked the Plan to pay for procedure code 99100. You say that you have provided medical records to substantiate payment. The Plan denied your request. The Plan says this code is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that codes given a status indicator of 'B' are never separately payable.  Payment for these services is bundled into payment for other services provided.  In this case, procedure code 99100 has a status indicator of 'B' on the Medicare Physician Fee Schedule Database.          Therefore, we decided that the Plan does not have to pay for procedure code 99100 billed for date of service January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an abutment supported crown (D6058) and a custom fabricated abutment (D6057) provided by an out-of-network provider.  You asked the Plan to pre-approve an abutment supported crown and a custom fabricated abutment. You say that you would like the Plan to pay for half of the charges. The Plan denied your request. The Plan says the requested dental services are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an abutment supported crown (D6058) and a custom fabricated abutment (D6057) provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says you no longer have the health conditions to stay in the skilled nursing facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continuation of services is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes G0283 and J3420 provided on date of service June 29, 2021.  You asked the Plan to pay for procedure codes G0283 and J3420. You say that these services were medically necessary for this patient. The Plan denied your request. The Plan says code G0283 is not covered and code J3420 is considered experimental/investigational for the treatment of chronic pain.  The Plan must follow Medicare rules. Medicare rules state that stand-alone electrical stimulation for neuropathies (code G0283) is never covered.  In addition, 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 procedure codes G0283 and J3420. Our reviewer says that code J3420 is not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical value and effectiveness of the requested medication has not been documented for the treatment of chronic pain in the literature. There is no specific clinical rationale for the treatment. The review has determined that the items/services at issue in this case are not medically reasonable or 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 procedure codes G0283 and J3420 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes G0283 and J3420 provided on date of service June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) provided by a participating provider.  You asked the Plan to pre-approve a crown. You say that you want the Plan to approve this crown. The Plan denied your request. The Plan says this benefit has already been exhausted.  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 a crown per tooth once every five years.  We looked at the file and Medicare rules. Evidence was provided to show that a crown was provided to tooth #8 on September 12, 2018. Based on this information, we decided that the Plan's rules for coverage of a crown have already been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) provided by a participating provider.