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

 We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on March 27, 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 the appropriate modifier was not 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 70450 is a column II code to column I code 70496. 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 imaging services (procedure code 70450) provided to the enrollee on March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the enrollee on May 5, 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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) 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 HCPCS 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 must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (procedure code G0483) provided to the enrollee on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for supplies provided to the enrollee on February 17, 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 the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 supplies provided to the enrollee on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided May 12, 2021  You asked the Plan to pay for the medical supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the codes billed are not eligible for payment.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes S1015, & S8301 are not supported in the medical record. Specifically, per the National Physician Fee Schedule, the codes billed have a status of "I" and are not valid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided May 12, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on July 6, 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 an appropriate modifier was not billed in this case.  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 70450 is a column II code to column I code 70496. 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 imaging services (procedure code 70450) provided to the enrollee on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a stair glide.  You asked the Plan to pay for a stair glide. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift 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 pay for a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a mattress elevator, purchased on April 14, 2021.  You asked the Plan to pay for a mattress elevator. You say that the item should be covered. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a mattress elevator, purchased on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on June 22, 2021.   You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says you are responsible for the cost of non-covered services and the cost of any eyeglasses purchased after Plan paid benefits. On June 26, 2020 the Plan paid for lenses and frames provided to the member on June 12, 2020.  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. The Plan covers these services every 2 years.  We looked at the file and the Plan's rules. The file shows that the Plan paid for eyeglasses on June 26, 2020, therefore you have exceeded the Plan eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for progressive lenses provided on June 1, 2021.  You asked the Plan to pay for progressive lenses. You say that this is a medical expense because it follows a surgical procedure. You say that if the progressive lenses cannot be paid in full, then you would like the Plan to approve whatever Medicare allows for 2 standard bifocal lenses. The Plan denied your request. The Plan says that the Plan only covers eyeglasses if they are received after cataract surgery that includes insertion of an intraocular lens. Covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating).  The Plan must follow Medicare rules. The rules say that Medicare does not cover progressive lenses.  The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating).  We looked at the file, the Medicare rules and the Plan's rules. Medicare does not cover progressive lenses. The Plan covers eyeglasses after cataract surgery that includes standard frames and lenses as defined by Medicare; any upgrades are not covered. Therefore, we decided that the Plan does not have to pay for progressive lenses provided on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network imaging services provided to the enrollee on March 10, 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 must 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 imaging services provided to the enrollee on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab testing (81407, 81410) provided April 8, 2021.  You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says a bundled relationship exists between the billed codes.  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 81407 has a bundled relationship with code 81410. 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 lab testing (81407, 81410) provided April 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy provided from June 14, 2021, and  June 15, 2021.  You asked the Plan to pay for physical therapy. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are 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 did not pre-approve the services at issue. 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 physical therapy provided from June 14, 2021, and  June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for in situ hybridization cytopathology services (88121) provided on June 4, 2021.  You asked the Plan to pay for in situ hybridization cytopathology services. You say that this diagnosis supports medical necessity. The Plan denied your request. The Plan says this was a screening service.  The Plan must follow Medicare rules. Medicare rules say that when billing for bladder or urothelial tumor markers, diagnosis codes R31.21 or R31.29 must be listed as secondary with the primary neoplastic diagnosis.  We looked at the file and Medicare rules. Diagnosis R31.21 was billed as the primary diagnosis on this claim. Based on this information, we decided that Medicare rules for coverage of in situ hybridization cytopathology services have not been met. Therefore, we decided that the Plan does not have to pay for in situ hybridization cytopathology services (88121) provided on June 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for drugs provided to the enrollee on September 10, 2020.  You asked the Plan to pay for the drugs. You say that you do not agree that you should be reimbursed only to the allowed amount since there was an issue with processing the request. The Plan denied your request. The Plan says Medicare does not pay for oral out-patient medication  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for drugs provided to the enrollee on September 10, 2020.   Benefits for the drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more toward the extraction (D7140), comprehensive oral evaluation (D0150), bitewing x-ray (D0274) and panoramic x-ray (D0330) provided on July 12, 2021.  You asked the Plan to pay more toward the extraction (D7140), comprehensive oral evaluation (D0150), bitewing x-ray (D0274) and panoramic x-ray (D0330). You say that you were not satisfied with the treatment, so you went to another dentist. You say that you are on social security and don't have the money to pay. The Plan denied your request. The Plan says the claim processed correctly.    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, you also have a maximum benefit of two oral exams per calendar year, one bitewing x-ray per calendar year and one panoramic or full mouth series x-ray every three years. The Plan paid for the limited oral evaluation and panoramic x-ray provided on March 1, 2021 and paid for the comprehensive oral evaluation and bitewing x-ray provided on April 8, 2021, which exhausted your benefits. The extraction was covered at 50% per your dental benefits. Therefore, we decided that the Plan does not have to pay more toward the extraction (D7140), comprehensive oral evaluation (D0150), bitewing x-ray (D0274) and panoramic x-ray (D0330) provided on July 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) and the psychotherapy service (90832) rendered by the out-of-network (OON) provider on June 17, 2021 and  August 18, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the psychiatric diagnostic evaluation (90791) and the psychotherapy service (90832) rendered by the out-of-network (OON) provider on June 17, 2021 and August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies, life sustaining situation provided on April 5, 2021.  You asked the Plan to pay for ambulance oxygen and oxygen supplies, life sustaining situation. The Plan denied your request. The Plan says under the ambulance fee service, oxygen and other items and services provided as part of the transport are included in the fee service base payment rate and are not separately payable.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, is included in the fee schedule payment.  We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on November 18, 2020.  You asked the Plan to pay for lab tests. 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 lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81551, 88387) rendered by the out-of-network (OON) provider on August 6, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the laboratory services (81551, 88387) rendered by the out-of-network (OON) provider on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve semi electric hospital bed (E0260).  You asked the Plan to pre-approve the hospital bed. You say that the hospital bed is a medical necessity. The enrollee suffered a stroke and is partially paralyzed and has no use of her left arm or leg. The enrollee has arthritis and has great difficulties sitting up on her own. The Plan denied your request. The Plan says there was no documentation that pillows and wedges cannot meet the enrollee's needs or that she requires repositioning that an ordinary bed cannot provide.  The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:  1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  2. Requires attachments which can only be attached to a hospital bed; AND  3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  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 hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a request for a semi-electric hospital bed was made to elevate the enrollee's head more than 30 degrees and for frequent body positioning to reduce skin breakdown. However, there was insufficient documentation to show that simple means of repositioning and transfer assistance such as with pillows and cushions and attachable devices on a regular bed.  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 hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve semi electric hospital bed (E0260).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy provided on July 17, 2021, to July 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for physical therapy. You say that you would the appeal reprocessed and paid. The Plan denied your request. The Plan says the rendering physician is out-of-network. The Plan says that the referring provider is also out-of-network.  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 referring provider is also out-of-network. 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 physical therapy provided on July 17, 2021, to July 30, 2021, by an out-of-network (OON) provider.