Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99350) and prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service (99354) provided on January 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit and prolonged service(s) in the outpatient setting. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says there is no referral from a contracted network provider. The Plan also says that there was no authorization by the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit (99350) and prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service (99354) provided on January 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 12, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit after 
receiving scans and the scans showed that nothing was wrong. You feel that for this reason you should not be 
charged a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you 
are being charged the correct amount. 
 
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 had a follow-up visit with a specialist on August 12, 2021. Follow-up visits are subject to cost-sharing 
charges. Therefore, you are responsible to pay the $35 copayment.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. 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 a specialist visit provided on August 12, 2021.  
 
We note your complaint that you went through a lot of testing and were referred to an oncologist only to find 
out that nothing was wrong. Your complaint is a grievance that must be answered by the health plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology genetic testing coded 81529 provided on March 18, 2021.
You asked the Plan to pay for the oncology genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 81529 is oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis.
We find that CPT code 81529 is not supported in the medical record. Specifically, the documentation does not support that the genetic testing provided was ordered or approved by the ordering provider. Based on this information, we decided that Medicare rules for coverage of the oncology genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the oncology genetic testing coded 81529 provided on March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118). 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is insufficient published clinical literature demonstrating the safety and 
effectiveness in the Medicare population of this device. 
 
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 item. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
there is no evidence that this item is safe and effective for your medical condition. Additionally, there is no 
detailed upper extremity physical examination indicating that you are unable to use regular crutches. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crutch substitute (E0118).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 31, 2020, through February 20, 2020, billed with code OJGD1.
You asked the Plan to pay for the SNF services as billed. You say that the functional scores reported are correct and support the HIPPS code billed The Plan denied your request. The Plan says the documentation does not support the services as billed.
The Plan follows Medicare rules. Medicare rules say that SNF services are billed using a HIPPS code which has four digits for four case-mix groups as described in the Medicare rules section. Calculation of the proper HIPPS code takes into account the Resident Assessment Instrument (RAI) manual and PDPM calculation worksheet, which provides guidance on completing the Minimal Data Set (MDS) assessment. Reported diagnoses in Section I of the MDS assessment are used to help determine both the nursing case-mix group (third digit of the HIPPS code) and NTA case-mix group (fourth digit). 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 the SNF services as billed. Our reviewer says that the documentation does not support the diagnoses of malnutrition, endocarditis, and intravenous (IV) feeding. Our physician reviewer found no documentation was received showing the physician identified malnutrition, endocarditis, and IV feeding during the 60-day lookback period. No documentation received to support these as an active diagnosis within the last 7 days. 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 SNF services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 31, 2020, through February 20, 2020, billed with code OJGD1.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of home health/hospice aide (G0156) provided from September 7, 2019, to September 16, 2019.
You asked the Plan to pay for the services of home health/hospice aide. The Plan denied your request. The Plan says the treating provider is not Medicare certified and is not eligible to receive payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services of home health/hospice aide have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the services of home health/hospice aide (G0156) provided from September 7, 2019, to September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), extractions (D7210 x 2), guided tissue regeneration (D4266), and bone replacement graft (D7953 x 2) provided on June 17, 2021, by an out of network periodontist.
You asked the Plan to pay for the dental services. You say that this provider's office is listed on the provider's directory. The Plan denied your request. The Plan says dental services are covered when performed by a participating general dentist. The Plan also says you signed a treatment plan acknowledging $0 insurance coverage for the services that you received.
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 dental services you received are not among those covered under this benefit. Additionally, dental services received from a periodontist are not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), extractions (D7210 x 2), guided tissue regeneration (D4266), and bone replacement graft (D7953 x 2) provided on June 17, 2021, by an out of network periodontist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 74018 provided on June 20, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not separately payable.
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 74018 for the x-ray services is a column II code to column I code 74022.
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 x-ray services coded 74018 provided on June 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2300 power seat elevation feature is not covered because it is not primarily medical in nature. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scan you had on
March 12, 2021, and the office visit you had with a vascular surgeon on April 20, 2021.
You asked the Plan to waive the copayments for the duplex scan and the specialist visit. You say that the doctor cancelled your surgery, so you would like all of your copayments waived. The Plan denied your request. The Plan says you were charged these copayments 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 $25 copayment for ultrasounds and a $20 copayment for specialist visits. You have been asked to pay a $25 copayment for the duplex scan and a $20 copayment for the specialist visit.
The duplex scan falls within the ultrasounds benefit category and the visit with the vascular surgeon is a specialist visit. These copayments apply each time you have services, even if surgery is cancelled. This means that you have been asked to pay the correct amounts 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 copayments for the duplex scan you had on March 12, 2021, and the office visit you had with a vascular surgeon on April 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whirlpool tub.
You asked the Plan to pre-approve the tub. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the health plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
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 tub. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that you are homebound. There is no evidence that this request is expected to provide substantial benefit. The requested whirlpool will not serve a primarily medical need. 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 tub have not been met. Therefore, we decided that the Plan does not have to pre-approve a whirlpool tub.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the laboratory work. We decided that the Plan does not have to waive the copayment for the laboratory work.
You asked the Plan to waive the copayment for the laboratory work. You say that you were not notified of the $100 copayment. The Plan says that the outpatient hospital diagnostic procedures and tests have been paid and you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to waive the copayment for the laboratory work.
The records show that you were charged for laboratory work. The Plan says that you must pay a $100 copayment for the laboratory work. Based on the plan contract, however, you cannot be asked to pay more than a $40 copayment for the laboratory work. Therefore, we decided that the Plan has to reduce the copayment for the laboratory from a $100 copayment to a $40 copayment. Therefore, we decided that the Plan has to reduce the copayment for the laboratory work.
We also decided that the Plan does not have to waive the copayment for the laboratory work.
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 $40 copayment for the laboratory work. Therefore, we decided that the Plan does not have to reduce the copayment for the laboratory work.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited dental exam (D0140) provided on July 9, 2021.
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you are limited to one limited dental exam with dental code D0140 once per plan year. The claim history shows that you received dental code D0140 also on June 2, 2021, which the Plan paid for.
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.
We looked at the file, the Plan's contract and Medicare rules. The Plan contract shows that you are limited to one limited dental exam with dental code D0140 once per plan year. The claim history shows that you received dental code D0140 also on June 2, 2021, which the Plan paid for. Therefore, we decided that the Plan does not have to pay for the limited dental exam (D0140) provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (CPT 93976) provided to the enrollee on June 
17, 2021. 
 
You asked the Plan to pay for the scan. 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, the CPT Code Manual definition of code 93976 is "Duplex scan of arterial inflow and venous 
outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study." 
 
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 scan. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found CPT 93976 has a bundled relationship to 
CPT code 76856. Per the National Correct Coding Initiative (NCCI) edits, a modifier is allowed to unbundle 
the relationship of the two services, providing the medical documentation supports the use of an appropriate 
modifier. However, CPT 93976 was not billed to the health plan with an appropriate modifier to unbundle its 
relationship to 76856, therefore, 93976 cannot be considered for separate reimbursement. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a duplex scan (CPT 93976) provided to the enrollee on June 17, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy provided on January 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the chemotherapy. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the chemotherapy provided on January 13, 2021, by an out-of-network (OON) provider.