Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and appliance (E0673) provided on April 15, 2021.  You asked the Plan to pay for the pneumatic compression device and appliance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism 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 the pneumatic compression device (E0675) and appliance (E0673) provided on April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for physical therapy provided from August 24, 2021, to September 16, 2021.  You asked the Plan to waive the deductible for physical therapy. You say that you were told this service would be covered. The Plan denied your request. The Plan says the deductible applied was correct.  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 each therapy visit.      You are being asked to pay $616.08 for physical therapy. The item or service you asked the Plan to waive the deductible for falls within the benefit category of Outpatient Rehabilitation Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to each therapy visit. This cost sharing is a contractual obligation that had not been met at the time physical therapy was received on August 24, 2021, to September 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided from August 24, 2021, to September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the simple extractions (D7140) provided on April 1, 2021.  You asked the Plan to pay for the simple extractions. You say that you feel the enrollee should be due some reimbursement from the Plan for the dental plan he has and the services he has received leading up to the full extraction and denture replacements. The Plan denied your request. The Plan says this service is not a covered expense under the enrollee's 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 simple extractions (D7140) provided on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the external mobile cardiovascular telemetry with electrocardiographic recording (93229) rendered by the out-of-network (OON) provider on August 5, 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 external mobile cardiovascular telemetry with electrocardiographic recording (93229) rendered by the out-of-network (OON) provider on August 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for nurse practitioner services provided on July 21, 2021.  You asked the Plan to pay for nurse practitioner services. 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 member's terminal condition. The Medicare hospice benefit through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on July 8, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on July 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on August 15, 2021.  You asked the Plan to pay for the x-ray services. 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 71045 is a column II code to column I code 71110. 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 x-ray services coded 71045 provided on August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing provided on August 5, 2021.  You asked the Plan to pay for the services provided. You say that the testing may affect the enrollee's response to medications. The Plan denied your request. The Plan says the testing has not been shown to be useful.  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. In this case, there are insufficient medical records that document the enrollee's condition. There is no documentation that the medications being considered were derived from clinical factors. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided July 9, 2021.  You asked the Plan to pay for the tooth extractions. You say that you were not aware the Plan wouldn't cover the services. The Plan denied your request. The Plan says you do not have coverage for services provided OON.  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 tooth extractions when provided in-network.   We looked at the file and Medicare rules. 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 extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided July 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 1, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you were previously in the hospital and had to return 6 days later for dehydration. 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 $195 copayment for each one-way ambulance service.     The record shows you were transported to the hospital via ambulance on August 1, 2021. Therefore, you have been asked to pay a $195 copayment for the ambulance services. Ambulance services fall within the Ambulance Services 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 ambulance services provided on August 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the crown (D2740) provided on August 31, 2021.  You asked the Plan to pay more for the crown. You say that these services were not provided for cosmetic replacement but done out of necessity. The Plan denied your request. The Plan says the enrollee's annual maximum benefit has been met.  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 offers up to a $2,000 allowance for all covered dental services. The enrollee is responsible for 100% of charges beyond the $2,000 allowance.  The record shows that the enrollee met the annual maximum benefit while processing this claim for the August 31, 2021 date of service and the enrollee's annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the autograft for spine surgery (20936) provided on May 25, 2021.  You asked the Plan to pay for the autograft for spine surgery (20936). The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  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 20936 is autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure).  We find that CPT code 20936 is not supported in the medical record. Specifically, CPT code 20936 has a status indicator of B. This means that CPT code 20936 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the autograft for spine surgery (20936) have not been met. Therefore, we decided that the Plan does not have to pay for the autograft for spine surgery (20936) provided on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.  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 that the patient is a 74-year-old female admitted to acute care with acute respiratory failure and coronavirus pneumonia requiring oxygen and later intubation, antibiotics, steroids, and vasopressors. Recent notes show the patient still dependent on mechanical ventilation, tube feeds, and antibiotics for new infiltrates on chest x-ray, but slightly more alert.  Documentation describes the patient's prognosis as poor. The patient is still somewhat unstable and requires additional short-term acute care services that can be safely completed at the current facility. It is not clear if the patient is weanable at this point, however. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed and the patient is more stable.  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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan provided on July 23, 2021.  You asked the Plan to waive the copayment for a CT scan. You say that you were not told that you would owe an additional copayment for radiological services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $275 copayment for diagnostic radiology services.  You have been asked to pay the allowed amount of $208.04, which is less than the $275 copayment for a CT scan. A CT scan falls within the 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 copayment for a CT scan provided on July 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the breath hydrogen or methane test (91065) provided on September 15, 2021.  You asked the Plan to pay for the breath hydrogen or methane test. You say that you were all under the impression that the enrollee could be reimbursed for the out-of-pocket expense. The Plan denied your request. The Plan says this service is not a Medicare covered benefit and is excluded from coverage.  The Plan must follow Medicare rules. Medicare rules say that the lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the breath hydrogen or methane test have not been met. The record shows that this test was a small intestinal bacterial overgrowth (SIBO) test and is not covered. Therefore, we decided that the Plan does not have to pay for the breath hydrogen or methane test (91065) provided on September 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on October 7, 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 October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided on September 17, 2021.  You asked the Plan to pay for the CT scan. 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) scan coded 70450 provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided August 17, 2021.  You asked the Plan to pay for the periodontal maintenance. You say that you would like this covered as a dental cleaning. 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 pay for the periodontal maintenance (D4910) provided August 17, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 29, 2021.  You asked the Plan to pay for physician's services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  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 physician's services provided on June 29, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the breast ultrasounds (76642) provided on August 21, 2020 and September 21, 2020.  You asked the Plan to pay for the breast ultrasounds. You say that you would like reconsideration because this Plan is your primary insurer. The Plan denied your request. The Plan says that an explanation of benefits from the primary insurer is required.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. Therefore, we decided that the Plan has to pay for the breast ultrasounds (76642) provided on August 21, 2020 and September 21, 2020.   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 pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on May 28, 2021.  You asked the Plan to pay for the pneumatic compression device and sleeves. You say that intermittent compression devices are necessary to reduce risk of deep vein thrombosis. The Plan denied your request. The Plan says that this is not covered by Medicare.  The Plan follows Medicare rules. The rules 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 the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on May 28, 2021.