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

We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 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 testing is 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 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 July 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on May 27, 2021.

You asked the Plan to pay for the services provided. You say that the services were provided in good faith. The Plan denied your request. The Plan says there is no referring physician listed on the claim.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. The records do not show that the enrollee's primary care or attending physician referred the enrollee for care. 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 outpatient mental health services provided on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis provided on March 17, 2021 and March 18, 2021.

You asked the Plan to pay for the dialysis. You say that the attached medical records show the billed diagnosis code is valid for the claim. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says the claim was billed with an invalid primary diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules also say that Hospital-based and independent renal facilities must complete this item and it should include a primary diagnosis of end stage renal disease for patients with ESRD.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of dialysis have not been met. Specifically, the claim was not billed with the appropriate primary diagnosis code. Therefore, we decided that the Plan does not have to pay for the dialysis provided on March 17, 2021 and March 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospice room and board services provided from July 1, 2021, and July 3, 2021.

You asked the Plan to pay for the hospice room and board services. You say that this claim is being denied incorrectly. You also say that you would like this claim to be reprocessed because the enrollee is covered for Hospice services and the provider is participating with the Plan. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospice room and board services provided from July 1, 2021, and July 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical 
x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis 
(D1110) provided on June 9, 2020.

You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, and 
prophylaxis. You say that you say that nothing had ended to your knowledge. You also say that you had 
continuously been a member of the Plan for at least five years at the time these services were rendered. The 
Plan denied your request. The Plan says these services were rendered during a time when the dental plan was 
not in effect. The Plan also says that the dental plan became effective on January 01, 2021 and there were no 
previous dental plans on file prior to this effective date.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation 
(D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays 
(D0274), and prophylaxis (D1110) provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia services (99100) provided on September 
28, 2020.

You asked the Plan to pay for special anesthesia services. You say that this is supported in the records. The 
Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database 
(MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment 
for other services not specified.

We looked at the file and Medicare rules. Code 99100 has a status indicator of B, meaning it is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia services 
have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services 
(99100) provided on September 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on July 30, 2021.

You asked the Plan to pay for the services provided. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says the rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 25609 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 surgery services provided on July 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on May 18, 2021.

You asked the Plan to pay for the services provided. You say that the services were not available from a preferred provider. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

In this case, the CPT Code Manual definition of code 97597 is debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less. We find that CPT code 97597 is not supported in the medical record. Specifically, the records provided do not show that the billed code describes the services that were provided.

The file shows that CPT code 99350 was billed along with code 97597. We find that code 99350 may be eligible for payment when billed with this code pair. The claim provided does not show that the code was billed with a modifier suitable for payment. 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 wound care services provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on July 8, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that this service was in line 
with services that are covered under your dental plan. The Plan denied your request. The Plan says this service 
is not a covered benefit 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 
comprehensive periodontal evaluation (D0180) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (99217) provided on July 16, 2021.

You asked the Plan to pay for observation care discharge day management. You say that this was billed correctly. The Plan denied your request. The Plan says this must be billed with the initial and subsequent care codes.

The Plan must follow Medicare rules. Medicare rules say that when a patient remains in observation care for 3 or more days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for each day between the first day of observation care and the discharge date, and an observation care discharge CPT code 99217 for the observation care on the discharge date.

We looked at the file and Medicare rules. The discharge management at issue was not billed with claim lines for the initial and subsequent observation care codes as required. Based on this information, we decided that Medicare rules for coverage of observation care discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management (99217) provided on July 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure supplies provided on 
August 31, 2021.

You asked the Plan to pay for the services provided. You say that the prices were significantly less than any 
other supplier. The Plan denied your request. The Plan says they cannot issue payment for items received from 
a provider who is not certified by Medicare.

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 provider is not eligible to provide 
services under Original Medicare. The Plan had network providers available who could have provided the 
items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would 
require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the 
continuous positive airway pressure supplies provided on August 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance provided on April 13, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an 
appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.

The file shows that CPT code 76942 was billed with 76937. We find that CPT code 76942 may be eligible for 
payment when billed with this code pair. The claim information does not show that the service at issue was 
billed with a modifier suitable for payment. 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 ultrasonic guidance provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99211) computed tomography, 
cervical spine (72125) provided August 20, 2021.

You asked the Plan to pay for the diagnostic office visit. You say that the claim denied as no coverage for 
maintenance therapy, however the provider said they used this code in the past and it paid. The Plan denied 
your request. The Plan says these services are not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99211) computed tomography, cervical spine 
(72125) provided August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care evaluation and management service (99291) 
provided on January 17, 2021.

You asked the Plan to pay for critical care visit 99291. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 
99291 has a medically unlikely edit (MUE) value of 1 so this second unit of the code is not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of critical 
care visit 99291 have not been met. Therefore, we decided that the Plan does not have to pay for a critical care 
evaluation and management service (99291) provided on January 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a 2D cephalometric radiographic imaging (D0340), and a 2D oral/facial photographic imaging (D0350) provided by an out-of-network provider on July 16, 2021.

You asked the Plan to pay for a 2D cephalometric radiographic imaging and a 2D oral/facial photographic imaging. You say that these services were necessary, and the Plan should pay for this. The Plan denied your request. The Plan says D0340 and D0350 are not covered benefits.

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 a 2D cephalometric radiographic imaging (D0340), and a 2D oral/facial photographic imaging (D0350) provided by an out-of-network provider on July 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on August 6, 
2021.

You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The 
Plan denied your request. The Plan says this is 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 a computed tomography scan (70450) provided on August 6, 
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a diagnostic colonoscopy (45378) provided
on September 2, 2021.
You asked the Plan to waive the deductible for the diagnostic colonoscopy. You say that the services should be
billed as a screening procedure and not a diagnostic procedure. 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. Your
contract with the Plan says that there is a $750 deductible which applies to Outpatient diagnostic tests and
therapeutic services and supplies.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $750 deductible which applies to Outpatient diagnostic tests and
therapeutic services and supplies. The record indicates that these services were provided in an outpatient
facility. This cost sharing is a contractual obligation that had not been met at the time the diagnostic
colonoscopy was received on September 2, 2021. Therefore, we decided that the Plan does not have to waive
the deductible for a diagnostic colonoscopy (45378) provided on September 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and ground mileage (A0425) provided on July 25, 2021.
You asked the Plan to pay for the non-emergent ambulance transportation and ground mileage. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the enrollee's claims history indicates they were in an inpatient hospital status on this date of service.
The Plan must follow Medicare rules. Medicare rules say that transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient is covered by the prospective payment rate.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transportation and ground mileage have not been met. Payment for the ambulance services in this case is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and ground mileage (A0425) provided on July 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia services (99100) provided on January 21, 2021.

You asked the Plan to pay for special anesthesia services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99100 has a status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia services (99100) provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 27, 
2021.

You asked the Plan to pay for the dental service. You say that you had an exam and x-ray done. You say that 
you were advised that your tooth needed to be extracted. You also say that you do not understand why the 
services were denied. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan 
year. The Plan also says that the frequency limit has been exceeded.

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 and the service is listed as covered, the 
frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you 
received on January 12, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during incision and drainage 
services coded 22015 provided on December 29, 2020.

You asked the Plan to pay for the incision and drainage services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 22015. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the
incision and drainage services have not been met. Therefore, we decided that the Plan does not have to pay for
the assistant surgeon services during incision and drainage services coded 22015 provided on December 29, 
2020.