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

 We decided that the Plan does not have to pay for the bone density study provided on August 4, 2021.  You asked the Plan to pay for the services provided. You say that the reports support separate services. The Plan denied your request. The Plan says the claim denied correctly.  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 77080 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 bone density study provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on July 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the genetic testing. You say that you were unaware this would not be covered without prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on July 13, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus testing provided on July 16, 2021.  

You asked the Plan to pay for the testing services. You may have been exposed to Covid. The Plan denied your request. The Plan says there was no way to determine if the test was medically necessary.  

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.   

We looked at the file and the rules. In this case, there are insufficient medical records to show that the testing was provided due to signs and/or symptoms. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus testing provided on July 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound (76641), provided on July 30, 2020.  

You asked the Plan to waive the copayment for the ultrasound. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $50 diagnostic radiology copayment for outpatient diagnostic tests and therapeutic services and supplies.   

You have been asked to pay a $50 diagnostic radiology copayment for the ultrasound. This service 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 (76641), provided on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the compression stockings provided on June 3, 2021 to July 17, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the compression stockings. You say that the items should be covered. The Plan denied your request. The Plan says there are suppliers in-network who carry the compression stockings, and you could have received from an in-network supplier, including by requesting a special order.  Medicare rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services.   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 compression stockings provided on June 3, 2021 to July 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital care provided from May 5, 2021, to May 7, 2021.  You asked the Plan to pay for hospital care. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if a period of observation spans more than 1 calendar day, all of the hours for the entire period of observation must be included on a single line and the date of service for that line is the date that observation care begins.  We looked at the file and Medicare rules. The observation code G0378 was billed on 3 separate lines, which is not appropriate. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care provided from May 5, 2021, to May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of portable x-ray services rendered on June 29, 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 services are not covered.  The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.  We looked at the file and Medicare rules. Billed procedure code R0070 (transportation of portable x-ray equipment) has a status indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray services rendered on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the technical component of the neuromonitoring services provided on May 24, 2021.  You asked the Plan to pay for the technical component of neuromonitoring services. You say that this was medically necessary as ordered by the surgeon. The Plan denied your request. The Plan says this is not payable to this provider type. These services are paid to the facility which must provide them under arrangements.  The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The rules also indicate that in order to bill Medicare and receive payment, a provider must be enrolled in the Medicare program.  Although these services may be appropriate, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for the technical component of the neuromonitoring services provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 00140 provided on November 2, 2020.  You asked the Plan to pay for the anesthesia services. 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 00140 is anesthesia for procedures on eye; not otherwise specified.    We find that CPT code 00140 is not supported in the medical record. Specifically, this code was billed with an extracapsular cataract removal with insertion of intraocular lens prosthesis (code 66982). This means a surgical code was not appropriately billed to support the anesthesia code. 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 00140 provided on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for comprehensive pharmacogenetic panel testing provided on June 28, 2021.  

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this panel of tests is screening testing and will not affect the diagnosis or treatment of the enrollee.  

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 record does not show that this testing was needed to diagnose or treat a specific medical condition of the enrollee. This means that the testing was screening in nature. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for comprehensive pharmacogenetic panel testing provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0367), preventive procedures (D1999), maxillary interim partial denture (D5820), simple extractions (D7140), bone replacement grafts for ridge preservation (D7953), and adjunctive procedure (D9999) provided from April 29, 2021, to September 7, 2021.  You asked the Plan to pay for the cone beam CT capture and interpretation, preventive procedures, maxillary interim partial denture, simple extractions, bone replacement grafts, and adjunctive procedure. You say that your two teeth were falling out and implants are in the process of being placed. You also say that these are medical and dental procedures. The Plan denied your request. The Plan says these services are not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  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 cone beam computed tomography (CT) capture and interpretation (D0367), preventive procedures (D1999), maxillary interim partial denture (D5820), simple extractions (D7140), bone replacement grafts for ridge preservation (D7953), and adjunctive procedure (D9999) provided from April 29, 2021, to September 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 4, 2019, to January 2, 2020.  

You asked the Plan to pay for the services provided. You say that there should not be any reason the claim is not paid in full. The Plan denied your request. The Plan says the original agency did not submit medical records.  

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  

We looked at the claim submitted, the file and the Medicare rules. In this case, there are insufficient medical records to corroborate the billed services. The file shows that the Plan attempted to obtain additional information, but none was received. Based on this information, we decided that Medicare rules for completing the claim for the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 4, 2019, to January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on September 22, 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 services were not billed correctly.  The Plan must follow Medicare rules. The rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.   We looked at the file and Medicare rules. The file shows that the services were rendered to a registered inpatient but were not billed with the required POS code 21. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a therapeutic injection procedure provided on August 26, 2021.  

You asked the Plan to waive the copayment for the injection procedure. You say that you believe you should only be responsible for a 20% coinsurance for Part B drugs. 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 $245 copayment for surgery or other services provided at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.   

You have been asked to pay $189.19, which is less than the $245 copayment for the injection procedure. Please note that this is a separate charge from the drug itself. The record does not show that you were charged for the drug. The injection procedure falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 therapeutic injection procedure provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 26, 2021.  You asked the Plan to pay for the scaling. You say that you went for a dental cleaning and the hygienist said that you needed an additional service, which you said that if your plan did not cover it then you would not be getting it. You also say that the hygienist reassured you repeatedly that you would not be charged for it. 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 scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on June 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).  You asked the Plan to pre-approve IRF care. You say that the inpatient facility gives three hours of therapy per day, while the skilled nursing facility only does one hour three times a week. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility or home with home health services.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found based on the medical records provided, the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require an intensive rehabilitation therapy program. There is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your reported limited endurance with therapy. Care at the skilled nursing facility level appears to be appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) segmental pneumatic appliance (E0673) provided February 26, 2021.  You asked the Plan to pay for a pneumatic compression device and appliance. You say that the claim was denied because authorization was not obtained prior to surgery. You would like this claim reconsidered for payment based on medical necessity without an authorization. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) 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. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) segmental pneumatic appliance (E0673) provided February 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the radioactive tracer for identification of sentinel node (38792) provided on June 3, 2021.  You asked the Plan to pay for the radioactive tracer for identification of sentinel node. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the requested service code is not substantiated by the clinical documentation in the operative report submitted for review.  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 38792 is injection procedure; radioactive tracer for identification of sentinel node.  We asked our coder 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 radioactive tracer for identification of sentinel node. Our reviewer says that CPT code 38792 meets criteria for billing and reimbursement consideration. Our reviewer found although, injections were given in the same area, these are two separate chemicals, as one is a nonradioactive dye, and the second one is a radioactive tracer.  No documentation was found to support CPT 38792 cannot be performed at the same time as CPT 38900, and billed separately.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radioactive tracer for identification of sentinel node have been met. Therefore, we decided that the Plan has to pay for the radioactive tracer for identification of sentinel node (38792) provided on June 3, 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.