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

We decided that the Plan does not have to pay for the ambulance transport provided on May 18, 2021.
You asked the Plan to pay for the ambulance transport. You say that the patient was not in hospice at the time of transport. You say that the patient became effective after the transport was complete and the claim should be paid. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
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 ambulance transport provided on May 18, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on April 14, 2020, to April 18, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a review of the records support DRG 689, and payment of DRG 871 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case are not supported by the medical records. Our physician reviewer found the review has determined that the records did not support the coding of the provider's DRG 871. The plan's DRG 689 was correct. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on April 14, 2020, to April 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray, resin-based composite and endodontic therapy provided on June 4, 2021.
You asked the Plan to pay more for the limited oral evaluation, intraoral x-ray, resin-based composite and endodontic therapy. You say that you were referred to this doctor and he required his own x-ray and evaluation. You say that you are living on a limited income and the balance of the charge is beyond what you can afford. 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, the Plan is only obligated to pay the allowed amount for an intraoral x-ray, resin-based composite and endodontic therapy from an out-of-network provider. You are responsible the charges above what the Plan pays. You also have a maximum benefit of one limited oral evaluation per plan year. The Plan paid for the limited oral evaluation provided on May 11, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray, resin-based composite and endodontic therapy provided on June 4, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography services coded as 70544 provided on November 9, 2020.
You asked the Plan to pay for the magnetic resonance angiography services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier has not been billed with this service.
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 magnetic resonance angiography services is a column II code to column I code 70551. 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 magnetic resonance angiography services coded as 70544 provided on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided July 20, 2021.
You asked the Plan to pay for the gingival irrigation and localized delivery of antimicrobial agents. You say that you required deep cleaning because of missed appointments due to the pandemic. The Plan denied your request. The Plan says these services are not covered under your benefits. Additionally, you signed a treatment plan accepting financial responsibility for the services.
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 gingival irrigation - per quadrant (D4921) and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder detect and Cxbladder monitor testing provided on January 19, 2021.
You asked the Plan to pay for the Cxbladder detect and Cxbladder monitor testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Cxbladder testing identified with codes 0012M and 0013M are non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cxbladder detect and Cxbladder monitor testing have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder detect and Cxbladder monitor testing provided on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the topical application of fluoride varnish (D1206) provided July 6, 2021.
You asked the Plan to pre-approve the fluoride varnish. You say that you feel the denial is in error. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve the topical application of fluoride varnish (D1206) provided July 6, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on May 26, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport does not meet the Medicare coverage guidelines.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the reviewed documentation indicates that the enrollee was not bed-confined. The ambulance record stated that the enrollee was ambulatory with assistance and had no medical issues requiring constant monitoring documented.
The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on May 26, 2021. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on May 26, 2021. The documentation did not support that the ambulance transport on May 26, 2021 was medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded as 99100 and 99140 provided on February 8, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like these claims reprocessed based on the medical documentation. The Plan denied your request. The Plan says payment is always bundled into payment for other services not specified and no separate payment is made per Medicare rules.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). The CPT Code Manual definition of code 99140 is anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 and 99140 is not supported in the medical record. Specifically, CPT codes 99100 and 99140 have a status indicator of B meaning that payment for these services are always bundled into another procedure. Separate payment is not made for CPT code 99100 and 99140.
Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 and 99140 provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), drugs dispensed in the office for home use (D9630) and inhalation of nitrous oxide (D9230) provided on May 17, 2021.
You asked the Plan to pay for the dental services. You say that you have had dental services covered on appeal in a previous year and feel these services should be covered as well. The Plan denied your request. The Plan says these services are 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 the oral hygiene instructions (D1330), drugs dispensed in the office for home use (D9630) and inhalation of nitrous oxide (D9230) provided on May 17, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 16, 2021.
You asked the Plan to pay for the physical therapy services. You say that the physical therapy services The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on July 23, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that the documentation supports the service as billed. The Plan denied your request. The Plan says an appropriate modifier was not billed to bypass the NCCI edit.
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 76705 is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the fracture brace you received on July 19, 2021.
You asked the Plan to waive the coinsurance for the fracture brace. You say that you did not get a prosthetic, you got a cast. You do not think you should have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for prosthetics and related supplies, including braces. You have been asked to pay 20% coinsurance for the fracture brace. The fracture brace you received falls in the prosthetics and related supplies benefit category because page 90 of your Evidence of Coverage explicitly states that braces are part of this benefit. This includes fracture braces. 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 fracture brace you received on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from December 28, 2020, to January 7, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were in the hospital for back surgery, but you were also treated for the Coronavirus while you were there. You said that you understand the charges, but you would like some help with the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that its Coronavirus copayment waiver program ended on June 30, 2020.
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 $225 copayment per day for days 1-7, and a $0 copayment per day for additional days for inpatient hospital care.
Records show that you were in the hospital for 10 days. You were charged a $225 copayment per day for the first 7 days, for a total of $1575. 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 inpatient hospital services you received from December 28, 2020, to January 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided on April 30, 2021.
You asked the Plan to pay for the duplex scan of extremity veins. You say that you would like this claim reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says this diagnosis submitted for the services billed is not a payable diagnosis code based on Medicare rules.
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 coverage for CPT code 93970 is not supported in the medical record. Specifically, according to Medicare rules there are specific diagnosis codes that must be billed with the provided service. The billed diagnosis code, Z03.89, is not among those covered diagnosis codes. Based on this information, we decided that Medicare rules for coverage of the duplex scan of extremity veins have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided on April 30, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for a sleep study, unattended, simultaneous recording: heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone) and sleep time (CPT 95800) provided on June 21, 2021.
You asked the Plan to pay for the sleep study. You say that the sleep study was medically necessary. The Plan denied your request. The Plan says that the polysomnogram (PSG) requires a valid diagnosis and must meet coverage criteria.
The Plan follows Medicare rules. Medicare rules say that effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the sleep study. Our reviewer says that the sleep study was medically necessary. Our physician reviewer found according to the applicable NCD 240.4.1: "Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility."
The enrollee in this case underwent a home sleep study with the WatchPAT device. The code billed is defined in the following manner, "refers to a sleep study, unattended, simultaneous recording: heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone) and sleep time." The enrollee's sleep test would have met these requirements for use of the code, and it is otherwise covered by the NCD. The notes from the enrollee's primary care physician otherwise presented signs and symptoms to support a diagnosis of OSA. This would meet Medicare criteria for coverage. 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 sleep study have been met. Therefore, we decided that the Plan has to pay for a sleep study, unattended, simultaneous recording: heart rate, oxygen saturation, respiratory analysis
(e.g., by airflow or peripheral arterial tone) and sleep time (CPT 95800) provided on June 21, 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 pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that this device is medically necessary. The Plan denied your request. The Plan says the requested ventilator is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that this device is not medically reasonable and necessary. Our physician reviewer found you have been diagnosed with COPD, although the records do not include pulmonary function testing for confirmation. The patient also has congestive heart failure and obstructive sleep apnea, without details in the record. Arterial blood gases test show CO2 retention during a recent acute illness. The patient may benefit from bilevel positive airway pressure during sleep.
Certain bilevel positive airway pressure devices can provide the average volume-assured pressure support mode of support, at less cost to the patient than a ventilator. Medicare does not cover a ventilator when used as BiPAP. The denial of the ventilator is upheld. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.