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

We decided that the Plan does not have to pay for the respiratory virus laboratory coded 87631 provided on
November 27, 2020.
You asked the Plan to pay for the respiratory virus laboratory. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 87631 is infectious agent detection by nucleic acid (DNA
or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
We find that CPT code 87631 is not supported in the medical record. Specifically, the submitted documentation
supports more than 5 targets. This means there is a more appropriate code to be billed for the services rendered.
Based on this information, we decided that Medicare rules for coverage of the respiratory virus laboratory have
not been met. Therefore, we decided that the Plan does not have to pay for the respiratory virus laboratory
coded 87631 provided on November 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 3, 2021.
You asked the Plan to pay for the laboratory 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 a covered benefit.
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 laboratory testing 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 provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ear wax removal provided on May 25, 2021.
You asked the Plan to waive the deductible for the ear wax removal. You say that you believed the ear wax removal would be covered under the $35 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 the ear wax removal.
The ear wax removal you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to the ear wax removal. This cost sharing is a contractual obligation that had not been met at the time the ear wax removal was received on May 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ear wax removal provided on May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of an interspinous spacer.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee has had prior conservative treatment without significant pain relief. The Plan denied your request. The Plan says there is lack of evidence to support interspinous spacer devices as safe and effective as the gold standard of surgical decompression.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous distraction devices are experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of an interspinous spacer.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional occupational therapy visits.
You asked the Plan to pre-approve 8 additional occupational therapy visits. You say that you are requesting an appeal for 8 occupational therapy visits. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
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 8 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the patient has had prior therapy and is at max functional potential for hygiene, grooming, bathing, transfers, toileting and dressing. Our reviewer says that there has been ample time for patient/staff instruction based on the already approved therapy and the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine and administration provided on December 19, 2020.

You asked the Plan to pay for Zoster (shingles) vaccine (90750) and immunization administration (90471). You say that the vaccine should be covered as reasonable and necessary. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Medicare Part B benefit.

Medicare Part B does not pay for or provide Zoster (shingles) vaccine (90750) and immunization administration (90471). The Plan follows the same rules. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and administration provided on December 19, 2020.

Benefits for Zoster (shingles) vaccine (90750) and immunization administration (90471) may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited (76642) provided May 7, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you were told your mammogram would have a $0 copayment The Plan denied your request. The Plan says the copayment was applied correctly
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each X-ray service. You have been asked to pay a $15 copayment for the ultrasound. The ultrasound 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 the ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited (76642) provided May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 4.

You asked the Plan to pre-approve a crown. You say that you are experiencing pain around your tooth. You also say that your tooth is worn down. The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown due to decay or trauma requiring a crown.

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 crown when the services are medically necessary and reasonable. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a crown. Our reviewer says that the crown is not medically necessary. Our physician reviewer found the provided documentation does not indicate that there is significant coronal breakdown due to caries or fracture to warrant a crown restoration. Therefore, the reviewer found that the requested crown is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown have not been met. Specifically, the file does not show there is enough breakdown to warrant a crown. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 4.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to hold the member harmless for continued skilled nursing facility (SNF) services
after April 25, 2021.

You asked the Plan to hold the member harmless for SNF care. You say that you would like reconsideration
because you were not told that this service would not be covered. The Plan denied your request. The Plan says
that there is no authorization and the member no longer required skilled nursing facility services.

The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.

We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before April 25, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Of note, the record indicates that
this provider is in-network with the Plan. It is the burden of the Health Plan to substantiate their denial and
forward any pertinent information from network providers. Therefore, we decided that the Plan has to hold the
member harmless for continued skilled nursing facility (SNF) services after April 25, 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 provided by a chiropractor on May 4, 2021.

You asked the Plan to pay for the office visit (99202). You say that you were not told only certain services are covered. The Plan denied your request. The Plan says only manual manipulation of the spine is covered.

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 office visit provided by a chiropractor on May 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-contracted provider
on September 21, 2019 through September 30, 2019.
You asked the Plan to pay for inpatient hospital care. You say that you would like this claim reprocessed and
fully reimbursed. The Plan denied your request. The Plan says based on coding guidelines and the
documentation in the medical record, K92.2 is not supported as an additional diagnosis.
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.
In this case, you billed the inpatient services provided with K92.2 - Gastrointestinal hemorrhage, unspecified.
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 inpatient hospital care. Our reviewer says
that initially gastrointestinal bleed was in the differential but was not supported by the documentation. Our
physician reviewer found the medical records do not support the billing of secondary diagnosis code, K92.2 -
Gastrointestinal hemorrhage, unspecified.
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 care provided by a non-contracted provider on September 21, 2019 through September
30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on January 4, 2021 and January 6, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken and the code should be reprocessed for prompt payment. 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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on January 4, 2021 and January 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the hip replacement and self-administered drugs
provided from February 22, 2021, through February 24, 2021, and May 24, 2021, through May 25, 2021.
You asked the Plan to waive the cost for the hip replacement and self-administered drugs. You say that you
were told you owe $911 but received no explanation on the amount. The Plan denied your request. The Plan
says the claims reprocessed to remove the $112 and $84.67 charges. The remaining charges processed
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for outpatient surgery at an in-network outpatient hospital.
You have been asked to pay a $350 copayment for each hip replacement. The hip replacement falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part
B. Therefore, you are responsible for the full cost of the self-administered drugs billed.
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 cost for the hip replacement and self-administered drugs provided from
February 22, 2021, through February 24, 2021, and May 24, 2021, through May 25, 2021.
Benefits for the hip replacement and self-administered drugs may be available under Medicare Part D. Contact
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies coded 95912 provided on March 8, 2021.

You asked the Plan to pay for the nerve conduction studies. 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 supported by the documentation.

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 95912 is nerve conduction studies; 11-12 studies.

We find that CPT code 95912 is not supported in the medical record. Specifically, the documentation submitted did not include documentation to support that nerve conduction studies; 11-12 studies was performed; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded 95912 provided on March 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on February 8, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken and the code should be reprocessed for prompt payment. 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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on February 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagogastroduodenoscopy (43239) provided on January 26, 2021.
You asked the Plan to pay for the esophagogastroduodenoscopy. You say that this service was not related to the enrollee's hospice diagnosis and you would like this claim to be reprocessed for payment. 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. 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 January 11, 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 the esophagogastroduodenoscopy (43239) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing, 1 to 3 teeth per quadrant,
(D4342 x 2) provided on April 28, 2021.
You asked the Plan to pay for the dental services. You say that you paid what was quoted for you. You say that
you received a bill for $53. You say that you received another bill for $244. You say that you believe that the
provider billed the services incorrectly. You also say that you feel you should not be responsible for this bill.
The Plan denied your request. The Plan says the medical records indicate that the claim was billed correctly.
The Plan says that scaling and root planing is not listed as a covered service. The Plan says that your call to the
plan was regarding dental providers only. The Plan also says that the during the provider's call, they did not
verify if scaling and root planing was 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling and root planing are not
among those covered under this benefit. Additionally, the record shows that the services were billed correctly.
Therefore, we decided that the Plan does not have to pay for the scaling and root planing, 1 to 3 teeth per
quadrant, (D4342 x 2) provided on April 28, 2021.