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

We decided that the Plan does not have to pay for the transplant related lodging, meals and transportation (S9975) provided from June 3, 2019, through June 25, 2020.
You asked the Plan to pay for transplant related services. You say that you would like these claims reprocessed as you were unaware there was a deadline. The Plan denied your request. The Plan says these claims were filed after the deadline and some claims are unrelated to the transplant in question.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows and you acknowledge that a claim for transplant related services was not filed until July 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the transplant related lodging, meals and transportation (S9975) provided from June 3, 2019, through June 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic ultrasound rendered on August 19, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 76856 (pelvic ultrasound) and 93975 (vascular study). Code 76856 is a column II code with a modifier indicator of 1 when billed with column I code 93975. Code 76856 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the pelvic ultrasound rendered on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 18, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, cytopathology, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 18, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 3, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell out of a chair and your daughter contacted the ambulance service. You also say that you had no option but to accept or reject services of a first responder. The Plan denied your request. The Plan says the ambulance was called, and you refused to be transported to an emergency facility. The Plan also says that because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says intermittent therapy can safely be received in a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee has stabilized medically necessary, and has been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). The enrollee no longer requires daily skilled nursing and/or skilled therapy services. She could benefit from continued intermittent services at a lower level of care. Although the enrollee made slow progress with therapy, her functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. She can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services is not 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided on June 9, 2021.
You asked the Plan to pay for fluoride application with varnish. You say that this service should be covered as part of your cleaning, and the provider did not inform you that this was not a covered service. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
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 topical application of fluoride varnish (D1206) provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the silicone breast (L8030), and mastectomy bra (L8000), provided on June 30, 2021.
You asked the Plan to waive the coinsurance for the silicone breast and mastectomy bra. You say that the items 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 prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance for the silicone breast and mastectomy bra. These items fall within the prosthetic devices 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 coinsurance for the silicone breast (L8030), and mastectomy bra (L8000), provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) purchased on May 1, 2021.
You asked the Plan to pay for the eyeglasses. You say that you disagree with this denial. The Plan denied your request. The Plan says routine vision services received out-of-network are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider in the Plan's specified routine vision vendor network. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2200) purchased on May 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge (99217) provided on April 5, 2021.
You asked the Plan to pay for the observation care discharge. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between 99217 and 93016 as well as 99217 and 93018.
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 the
observation care discharge is a column II code to column I codes 93016 and 93018. 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 observation care discharge (99217) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 12, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you have had these appointments before without copayments. The Plan denied your request. The Plan says you have been charged 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 $45 copayment for each specialist office visit.   You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall 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 office visit provided on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the
thorax, diagnostic; without contrast material (71250) provided on August 24, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $50
copayment for a Medicare-covered diagnostic computed tomography (CT) scan at a free standing provider.
You have been asked to pay a $50 copayment for the Medicare-covered CT scan rendered by a free standing
provider. 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 computed tomography (CT) scan of the
thorax, diagnostic; without contrast material (71250) provided on August 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures (97112) and therapeutic activities (97530) provided on August 10, 2021, through August 12, 2021.
You asked the Plan to pay for the therapeutic services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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. 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 therapeutic services. Our reviewer says that CPT code 97112 does not meet criteria for billing or reimbursement consideration. The documentation does not support the 2 units billed. Therapy visit documents "(x 18 min)". Unlike service-based CPT codes, time-based CPT codes can be billed as multiple units in 15-minute increments. One unit represents 15 minutes of therapy. Therapy must be provided direct one-to-one for at least 8 minutes to received one unit. Our reviewer found
CPT code 97530 does not meet criteria for billing or reimbursement consideration. The therapy report documents "(x 12 min); 1 units", however 3 units were billed for this CPT code. Therapy visit supports one unit. 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 therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures (97112) and therapeutic activities (97530) provided on August 10, 2021, through August 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision and interpretation of a unilateral extremity angiography on January 11, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 75710 (radiological supervision and interpretation of unilateral extremity angiography) and 37225 (endovascular revascularization). Code 75710 is a column II code with a modifier indicator of 1 when billed with column I code 37225. Code 75710 was not billed with an
appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the supervision and interpretation of a unilateral extremity angiography on January 11, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options and related accessories.
You asked the Plan to pre-approve a power wheelchair. You say that this item is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for the requested group 2 power wheelchair with multiple power options have not been met.
The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair with multiple power options is subject to the criteria listed in the Medicare rules section. 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 a power wheelchair. Our reviewer says that requested power wheelchair is not medically reasonable and necessary. Our reviewer found that the patient has a mobility deficit, but the documentation indicates that it does not significantly impair participation in mobility related activity of daily living (MRADLs) in the home. The patient is assist/set up for most MRADLs. The documentation reveals the patient is unable to overcome his mobility deficit with a cane, walker, or manual wheelchair due to falls and instability. The patient is able to safely maneuver the requested wheelchair in the home. The patient does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or evidence of being high risk for a pressure ulcer. As a result, the requested wheelchair along with the requested accessories are not medically reasonable and 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 a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair with multiple power options and related accessories
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture with
interpretation (D0367) provided on August 30, 2021.
You asked the Plan to pay for the dental service. You say that your bridge fell out. You say that you were not
able to get into the clinic. You say that you requested a pre-determination of benefits. You also say that you did
not know the services would not be covered. The Plan denied your request. The Plan says cone beam CT
capture with interpretation is not listed as 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 cone beam CT capture with
interpretation is not among those covered under this benefit. Therefore, we decided that the Plan does not have
to pay for the cone beam computed tomography (CT) capture with interpretation (D0367) provided on August
30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285, 93010, 93042) provided
June 9, 2021.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code.
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 99285, 93010, & 93042 are not supported in the medical record. Specifically,
diagnosis codes N39.0 and B37.41 cannot be reported together. Based on this information, we decided that
Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the
Plan does not have to pay for emergency room services (99285, 93010, 93042) provided June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five retainer crowns (D6740 x5), a resin-based composite of one surface (D2391), resin-based composite of two surfaces (D2392), and crowns (D2740) for tooth #'s 7, 8, 9, and 10.
You asked the Plan to pre-approve the retainer crowns, resin-based composites, and crowns. You say that your dental issues have been ongoing for months and you need these services. The Plan denied your request. The Plan says these services are not covered.
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 the retainer crowns, resin-based composites, and crowns. when the services are medically necessary and reasonable.
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 crowns. Our reviewer says that the crowns (D2740) for tooth #'s 7, 8, 9, and 10 are not medically reasonable and necessary Our physician reviewer found the record provided is insufficient to determine the medical necessity of the requested services. Our reviewer found that the record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer also found that the elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Retainer crown (D6740) is not listed as a covered benefit. The contract says that you are limited to up to four (4) restorative services (four teeth) every year. The record shows that you were approved for four fillings and your restorations benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns, resin-based composites, and crowns. have not been met. Therefore, we decided that the Plan does not have to pre-approve five retainer crowns (D6740 x5), a resin-based composite of one surface (D2391), resin-based composite of two surfaces (D2392), and crowns (D2740) for tooth #'s 7, 8, 9, and 10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on July 8, 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 separately payable.
The Plan must follow Medicare rules. The rules say that pre-operative visits on the same day as a minor surgical procedure are included in the global surgical package. We looked at the file and Medicare rules. The file shows that the services at issue were provided on the same day as a minor surgical procedure. Payment is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on July 8, 2021.