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

We decided that the Plan has to pay for the rural health clinic (RHC) services provided in the home on May 13,
2021.
You asked the Plan to pay for the RHC services. You say that you are an RHC and bill using an institutional
claim form. This does not have a place of service field. You state that this was billed correctly for your
institution. The Plan denied your request. The Plan says that payment is not allowed for this service because
place of service not appropriate for this service. A corrected claim can be submitted.
The Plan must follow Medicare rules. Medicare rules say that RHCs are paid using an AIR system. The rules
indicate that an RHC is only required to report the appropriate revenue code for the services rendered in order
to receive payment.
In this case, the facility is an RHC. The services were reported on revenue code 0525, which matches the
billing code reported 99335. It is noted that a billing code is not required for RHC claims, meaning that a denial
based on the code used not matching place of service is not appropriate. We find that the Plan's denial rationale
for this RHC service is not supported. Therefore, we decided that the Plan has to pay for the rural health clinic
(RHC) services provided in the home on May 13, 2021.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies rendered on February 9, 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 procedure code S1015 and S8301 are not covered.  The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.  We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on February 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive cardiac gene panel provided on July 28, 2020.  You asked the Plan to pay for the comprehensive cardiac gene panel. You say that you would like reconsideration because the services rendered were medically necessary and billed correctly. The Plan denied your request. The Plan says genetic testing is considered a non-covered screening test for patients unaffected by a relevant illness, injury, or signs/symptoms thereof.  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, the comprehensive cardiac gene panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any clinical information to verify why this testing was ordered or how it would affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiac gene panel provided on July 28, 2020.
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 based on the documentation provided there is no evidence that the enrollee requires services that are not currently available at the present setting where she is receiving care. The enrollee can remain at the current setting until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.  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: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the psychotherapy services (90832) provided on August 26, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says that there is no documentation of contact with the member's physician.  The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical Psychologist, if the patient consents, you must attempt to consult their attending or primary care physician about the provided services. This does not apply if a physician referred the patient to the Clinical Psychologist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Specifically, the record indicates that the member was referred to the Clinical Psychologist by their physician. Therefore, we decided that the Plan has to pay for the psychotherapy services (90832) provided on August 26, 2021.   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 office visit (99213) rendered by the out-of-network (OON) provider on July 7, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on July 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on April 11, 2021.  You asked the Plan to pay for the CT. 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 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 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 computed tomography (CT) coded 70450 provided on April 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an out-of-network provider on September 13, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that you were unaware that this provider was out-of-network. The Plan denied your request. The Plan says services provided by an out-of-network provider 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 a comprehensive oral evaluation when the services provided by an out-of-network provider are not covered.   We looked at the file and Medicare rules. Based on this information, services were provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by an out-of-network provider on September 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on September 23, 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 procedure code 71045 is 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 71045 (chest x-ray, single view) and 71046 (chest x-ray, 2 views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 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 chest x-ray rendered on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on June 1, 2021 to June 4, 2021 by an out-of-network (OON) provider.  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 were rendered by an out-of-network provider without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The 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 chiropractic services provided on June 1, 2021 to June 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve bilateral greater occipital nerve blocks with ultrasound guidance.  You asked the Plan to pre-approve occipital nerve blocks. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 occipital nerve blocks. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 77-year-old man who has chronic neck pain. He has tried chiropractic therapy without benefit. He is doing a home exercise program at this time. In this case, the Plan has mistakenly reviewed a request for facet joint injections. The provider's request clearly states this is for occipital nerve blocks. Occipital nerve blocks are medically reasonable and necessary for the enrollee's condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occipital nerve blocks have been met. Therefore, we decided that the Plan has to pre-approve bilateral greater occipital nerve blocks with ultrasound guidance.   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 waive the copayment for podiatry services provided on August 12, 2021.  You asked the Plan to waive the copayment for the podiatry services. You say that the services should be covered as your contract with the Plan states there's a $0 copayment for specialist visits. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $30 copayment for Podiatry services.       You have been asked to pay a $30 copayment for podiatry services. The record indicates that you are diagnosed with type 2 diabetes and have a foot ulcer. The provider who rendered this office visit is a podiatrist. 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 podiatry services provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vertical bitewings - 7 to 8 radiographic images (D0277) provided on October 5, 2021.  You asked the Plan to pay for the dental service. You say that the vertical bitewing images are standard of care for periodontal patients. The Plan denied your request. The Plan says vertical bitewing, 7 to 8 images, is not listed and therefore 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 vertical bitewing, 7 to 8 images, are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the vertical bitewings - 7 to 8 radiographic images (D0277) provided on October 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vasopneumatic device therapy provided on July 19, 2021.  You asked the Plan to pay for the vasopneumatic device therapy. The Plan denied your request. The Plan says the Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vasopneumatic device therapy have not been met. Specifically, the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy. Therefore, we decided that the Plan does not have to pay for the vasopneumatic device therapy provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for specialist services provided on July 27, 2021.  You asked the Plan to waive the copayment for the specialist services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $45 copayment for Physician/Practitioner services, including doctor's office visits.        You have been asked to pay a $45 copayment for specialist services. Specialist services 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 specialist services provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a regadenoson injection (J2785) and Rb82 rubidium (A9555) provided April 21, 2021.  You asked the Plan to waive the coinsurance for the regadenoson injection and Rb82 rubidium. You say that the services should be covered as you were told by Plan reps that you do not have a copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 5% coinsurance for Medicare Part B Prescription Drugs and a 20% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  You have been asked to pay a 5% coinsurance for a regadenoson injection (allowed amount is $237.48 x 5% = $11.87) and a 20% coinsurance for Rb82 rubidium (the allowed amount is $1,041.50 x 20% = $208.30). Regadenoson injections fall within the Medicare Part B Prescription Drugs benefit category and Rb82 rubidium falls within Outpatient Diagnostic Tests and Therapeutic Services and 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 a regadenoson injection (J2785) and Rb82 rubidium (A9555) provided April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated vehicle (K0800)  You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 operated vehicle. Our reviewer says that the requested power operated vehicle is not medically reasonable and necessary.  Our physician reviewer found that you are a 68-year-old male with a past medical history of hypertension, coronary artery disease and multiple sclerosis. Based on the medical records provided there is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the home. However, there is no specific documentation that your mobility deficit cannot be helped by the use of a manual wheelchair. In addition, there is no documentation that you can safely operate the requested power mobility device.  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 operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800)
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99337) rendered by the out-of-network (OON) provider on October 7, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99337) rendered by the out-of-network (OON) provider on October 7, 2021.