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

We decided that the Plan does not have to pay for the home infusion therapy rendered on March 10, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.

We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy rendered on March 10, 2021.

Benefits for these services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided from April 11, 2021, to April 15, 2021.
You asked the Plan to pay for the services provided. You say that hospitals use affiliated labs to ensure accurate results for testing. The Plan denied your request. The Plan says the claim was submitted incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code U0003 was billed with modifier 26. Modifier 26 is appended to a procedure code to indicate that the service provided was the reading and interpreting of the results of a diagnostic and/or laboratory service.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing provided from April 11, 2021, to April 15, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the limited duplex extremity scan provided on September 15, 2021, billed with code 93971.
You asked the Plan to pay for the billed code 93971. You say that this should be paid as multiple exams were performed on the same date. The Plan denied your request. The Plan says no NCCI modifier was used for this code as required.
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 the billed code 93971 is a column II code to column I code 93970. 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 interpretation of the limited duplex extremity scan provided on September 15, 2021, billed with code 93971.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the automatic external defibrillator 
(K0606), provided on June 26, 2021, through July 28, 2021.

You asked the Plan to waive the copayment for the automatic external defibrillator. You say that the item 
should be covered. The Plan denied your request. The Plan says the cost share was applied 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. 

You have been asked to pay a 20% coinsurance for the automatic external defibrillator. the automatic external 
defibrillator falls within the durable medical equipment (DME) and related supplies 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 the automatic external defibrillator (K0606), provided on 
June 26, 2021, through July 28, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy for the enrollee.

You asked the Plan to pre-approve the services. You say that the records show clinical support for approval. The Plan denied your request. The Plan says that the records do not show monthly participation in a medically-supervised weight management program.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically necessary. 

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 considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a body mass index of 41.5 kg/m2. The enrollee has multiple obesity co-morbid conditions (hypertension, hyperlipidemia, gastrointestinal reflux disease and degenerative joint disease), and has failed numerous self-dietary efforts as well as supervised weight loss with a registered dietitian. The enrollee obtained medical, dietary, psychiatric and surgical clearance after a multidisciplinary evaluation. There are no contraindications to bariatric surgery at this time, as the electrocardiography and labs were normal. 

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 been met. Therefore, we decided that the Plan has to pre-approve laparoscopic sleeve gastrectomy for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on September 14, 2020.

You asked the Plan to pay for the anesthesia 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 payable as billed.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has d. As the 
secondary insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-network provider on August 26, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that you went to two dentists in one day because you were sent for a root canal and then was told a root canal could not be done. The Plan denied your request. The Plan says the benefit limit for 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 limited oral evaluation once every plan year.

We looked at the file and Medicare rules. Evidence was provided that showed D0140 was provided by another provider on August 26, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-network provider on August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the hip (73502) provided on June 9, 2021, by an
out-of-network provider.

You asked the Plan to pay for an X-ray of the hip. You say that the services at issue were a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.

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 an X-ray of the hip (73502) provided on June 9,
2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on May 3, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that electrical nerve stimulation was provided. We looked at the file and the rules. It is inappropriate for a patient to visit his/her physician, physical therapist, or an outpatient clinic on a continuing basis for treatment of pain with electrical nerve stimulation. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.

The file shows that vasopneumatic device services were provided. We looked at the file and the rules. Further treatment of lymphedema by a vasopneumatic device rendered by a clinician after the educational visits is generally not reasonable and necessary unless the patient presents with a condition or status requiring the skills and knowledge of a physical or occupational therapist. Review of the available records shows that the services at issue were rendered by a licensed practical nurse (LPN). The file does not show that the provider is licensed to provide physical therapy where the services were provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.

The file shows that a nutria-pharmaceutical injection was provided. We looked at the file and the rules. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy with bladder tumor 
resection and fulguration provided on January 15, 2020.

You asked the Plan to waive the copayment for the cystoscopy with bladder tumor resection and fulguration. 
You say that you never received surgery and do not owe the copayment. The Plan denied your request. The 
Plan says you have been asked to pay the correct cost-sharing 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 $295 
copayment for surgery services at an in-network outpatient hospital.

You have been asked to pay a $295 copayment for the cystoscopy with bladder tumor resection and 
fulguration. The cystoscopy with bladder tumor resection and fulguration falls within the "Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical center" benefit category. 
The medical record shows you received this procedure on this date of service due to a recurrent urothelial
carcinoma of the bladder.

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 cystoscopy with bladder tumor resection and fulguration 
provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 22, 2021 by an out-of-network (OON) provider.

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 provided are not a covered benefit.

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 drug testing provided on July 22, 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 deductible for a nail trim and callus removal of the foot provided on August 26, 2021.

You asked the Plan to waive the deductible for the nail trim and callus removal. You say that you have already paid the $35 copayment. The Plan denied your request. The Plan says the correct amount was applied to your deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $750 deductible which applies to certain items and services, including podiatry services. 

The nail trim and callus removal you asked the Plan to waive the deductible for falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The office visit falls within the Podiatry Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. This cost sharing is a contractual obligation that had not been met at the time the nail trim and callus removal was received on August 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a nail trim and callus removal of the foot provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment with the Sanexas device and nutria-pharmaceutical injections provided on May 12, 2021, billed with codes G0283, 97016, 97150, 96372, J3490, J3490-KP, J3490-KQ, J3411, J3415, J3420, and three units of J3490-59.

You asked the Plan to pay for the services as billed. You say that the Sanexas treatment is medically necessary to treat neuropathic pain. The Plan denied your request. The Plan says these services are not billed properly.

The Plan must follow Medicare rules. Medicare rules say that therapy services are only covered when provided by, or under the direction of a physical therapist. The rules also require that the not otherwise specified code be
used to report compounded drugs (J7999). 

Review of the file and publicly available records, we find that the physical therapy services (G0283, 97016, 97150) at issue in this case were rendered by an NP who is not licensed to provide physical therapy in the State of Wisconsin. In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the treatment with the Sanexas device and nutria-pharmaceutical injections provided on May 12, 2021, billed with codes G0283, 97016, 97150, 96372, J3490, J3490-KP, J3490-KQ, J3411, J3415, J3420, and three units of J3490-59.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 17, 2021.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that when you received these same services many times in the past in the state you lived in previously, you never received a denial of coverage. You also say that you would like a list of providers that are in-network, and instructions how you can get prior approval to see an out-of-network provider. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93000) provided on August 25, 2020.
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says it is the provider's responsibility to bill the Primary Group Health Plan before submitting to the member's secondary payer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the electrocardiogram until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93000) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroid stimulating hormone (84443) provided April 2, 2021.

You asked the Plan to pay for the thyroid testing. You say that the enrollee had already established care with the doctor and wishes to continue seeking services for this condition under this physician at this location. The facility has requested in network participation. The Plan denied your request. The Plan says this same service was billed by another provider for the same date of service that was processed and paid on 04/13/2021.

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 84443 is thyroid stimulating hormone (TSH). 

We find that CPT code 84443 is not supported in the medical record. Specifically, the records show that this is a duplicate of a claim for the same service and the same date of service, that has already been processed and paid by another provider. Based on this information, we decided that Medicare rules for coverage of the thyroid testing have not been met. Therefore, we decided that the Plan does not have to pay for the thyroid stimulating hormone (84443) provided April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), periodontal scaling and root planing (D4341) and localized delivery of antimicrobial agents (D4381) provided on August 4, 2021.

You asked the Plan to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), periodontal scaling and root planing (D4341) and localized delivery of antimicrobial agents (D4381). You say that you are writing to appeal the decision not to pay the dental bill. You say that you have already paid for these services and are looking for a refund. 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 year, one panoramic x-ray every three years and periodontal scaling and root planing every three years. The Plan paid for the comprehensive oral evaluation and panoramic x-ray provided on March 5, 2020 and paid for the periodontal scaling and root planing provided on March 12, 2020, which exhausted your benefits. The localized delivery of antimicrobial agents remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), periodontal scaling and root planing (D4341) and localized delivery of antimicrobial agents (D4381) provided on August 4, 2021.