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

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic back pain and has been treated with left T5 to T8 RFA on March 1, 2021 and right T5 to T8 RFA on March 23, 2021. The request is for T7 to T8 RFA. The Medicare criteria states that no more than two RFA sessions will be reimbursed per rolling 12 months. The repeat RFA is 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 pre-approve repeat radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not separately payable.
Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on January 14, 2021.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 22, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Per LCD L36358, the requested cardiovascular risk assessment panel is not a covered service. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on February 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on December 17, 2020.

You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.

The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.

For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. 

We looked at the file and Medicare rules. The billed primary, first-listed diagnosis, F01.50, vascular dementia without behavioral disturbance, is a manifestation code that requires the underlying condition to be sequenced first. Based on this information, we decided that Medicare rules for coverage of a psychiatric diagnostic evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on December 17, 2020.
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 June 22, 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 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 physician services provided to the enrollee on June 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on January 6, 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 due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first for review.
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 practitioner services provided to the enrollee on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from February 27, 2021, to February 28, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you don't think you are responsible for this bill, because you had to go to the hospital for blood clots as a result of the COVID-19 vaccine. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 per day for days 1-5 for inpatient hospital care. 

Records show that you received inpatient hospital services for one night. You were charged a $200 copayment for this service.

This means that you have been asked to pay the correct amount based on your contract with the Plan. There is no provision in your contract for a waiver of this amount even if the services are needed as a result of complications from the COVID-19 vaccine. 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 inpatient hospital services you received from February 27, 2021, to February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 and 99140 provided on March 2, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says these claims are not eligible for payment based on Medicare rules.
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 99100 and 99140 are not supported in the medical record. Specifically, CPT codes 99100 and 99140 have a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT codes 99100 and 99140. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 and 99140 provided on March 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips to an eye doctor appointment.
You asked the Plan to pre-approve the additional trips. You say that you need more trips so you can go to this appointment. The Plan denied your request. The Plan says you have used up the 30 trips you are allotted for the year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips to an eye doctor appointment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a rhythm electrocardiogram report (93042) provided on January 22, 2021.
You asked the Plan to pay for a rhythm electrocardiogram report. You say that this was a separate service. The Plan denied your request. The Plan says this is not separately payable without a modifier.
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 12053. 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 a rhythm electrocardiogram report (93042) provided on January 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97163) provided on April 6, 2021.
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code to bill for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 97163 is not supported in the record. Specifically, the record shows that this claim was billed by a nurse practitioner. There is no evidence that nurse practitioner was present to directly supervise the services provided. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services (97163) provided on April 6, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a biceps tendon repair (23430) provided on October 5, 2020.
You asked the Plan to pay for a biceps tendon repair. You say that this is separately payable. The Plan denied
your request. The Plan says the records do not indicate this was a distinct service.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service from the column I code, 23472. Specifically, the records do not indicate that this was a different patient
encounter, different surgery, different site, separate incision/excision, or separate injury. Based on this
information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been
met. Therefore, we decided that the Plan does not have to pay for a biceps tendon repair (23430) provided on
October 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on August 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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 the services (70450) provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services you received on July 2, 2021.
You asked the Plan to pay for the dental services. You say that you used a network dentist, so you don't know why these services weren't covered. The Plan denied your request. The Plan says you have exhausted your $1000 annual dental benefit maximum for the year.
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 because you had already exhausted your $1000 annual dental benefit prior to the claim for this date of service being processed. Therefore, we decided that the Plan does not have to pay for dental services you received on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator, provided on June 25, 2021.
You asked the Plan to pay for the portable oxygen concentrator. You say that the item is medically necessary.
The Plan denied your request. The Plan says you purchased the equipment through a non-Medicare certified
provider.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator,
provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with an otolaryngologist on July 12, 2021.
You asked the Plan to waive the copayment for the otolaryngology visit. You say that you don't think you should have to pay this copayment because the doctor did nothing for you. You said the doctor looked in your ear and said there was no wax but didn't do any additional testing. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 for specialist visits.
You have been asked to pay a $35 copayment for the otolaryngology visit. The otolaryngology visit falls within the specialist visits benefit category. This copayment applies each time you visit a specialist, regardless of the extent of services you receive. 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 visit you had with an otolaryngologist on July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of benign tumor or cyst of mandible (21040) and an unlisted procedure of the dentoalveolar structures (41899) provided on January 29, 2021.
You asked the Plan to pay for an excision of benign tumor or cyst of mandible and an unlisted procedure of the dentoalveolar structures. You say that the procedures at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the procedures at issue are not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.
Therefore, we decided that the Plan does not have to pay for an excision of benign tumor or cyst of mandible (21040) and an unlisted procedure of the dentoalveolar structures (41899) provided on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 3, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 8, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), provided
on July 14, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the service was
medically necessary. The Plan denied your request. The Plan says this is not a covered service.
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
comprehensive periodontal evaluation (D0180), provided on July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from March
29, 2021, to April 22, 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 claim is missing the appropriate G code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that this home health claim is not supported in the medical record. Specifically, an appropriate G code
was not billed on line 8. 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 home health services provided
to the enrollee from March 29, 2021, to April 22, 2021.