Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the requested dental services.
You asked the Plan to provide coverage for these dental services. You say that these dental services should be
covered by the Plan. The Plan denied your request. The Plan says the requested services are not covered as
requested. We overturned the Plans denial. The Plan requested a reopen and stated that the request was
for a retainer crown (D6752) for tooth #3 and a pontic (D6242) for tooth # 4 versus what was ultimately
approved by us which was the pontic (D6242) for tooth #3 and the retainer crown (D6752) for tooth # 4.
The Plan states that the service requests were made for the incorrect tooth numbers and therefore cannot be
approved. The Plan understands that the provider made an error in the request, but this must be remedied by the
provider and cannot be changed by the Plan.
The Plan is correct in this case. Medicare does not cover dental services. 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 services requested were done so in error and needed
to be resubmitted with the correct codes for the correct tooth numbers.
Neither the Plan nor the IRE can change or modify the request to correct the error for you because it can be
inferred that an error was made and possibly determined what the request was supposed to have been.
Therefore, we decided that the Plan does not have to provide coverage for a retainer crown-porcelain fused to
noble metal (D6752) and a pontic-porcelain fused to noble metal (D6242) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the endoscopy services (43239, 43450) provided on August 12, 2021.  You asked the Plan to waive the copayment for the endoscopy services. You say that this cost should be covered by your Plan. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.  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 $340 copayment for surgery services provided in an ambulatory surgical center.   You have been asked to pay a $340 copayment for the endoscopy services. Endoscopy services fall within the surgical services benefit category, and in this case the procedures were provided in an ambulatory surgical center. 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 endoscopy services (43239, 43450) provided on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the out-of-country emergency room visit provided from July 15, 2021, to July 17, 2021.  You asked the Plan to pay for the out-of-country emergency room visit. You say that you feel that this service should be covered. The Plan denied your request. The Plan says a valid itemized bill for the reimbursement for an out-of-country emergency room visit was not received.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the out-of-country emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for the out-of-country emergency room visit provided from July 15, 2021, to July 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 17, 2021, by an OON provider.  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 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 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 laboratory services provided on June 17, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray of the abdomen (74018) provided on August 30, 2021.  You asked the Plan to pay for the x-ray of the abdomen. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says and edit exists between CPT codes 74018 and 74240.  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 74018 is a column II code to column I code 74240. 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 of the abdomen (74018) provided on August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital observation services coded G0378 provided from June 3, 2021 to July 2, 2021.  You asked the Plan to pay for the hospital observation 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 G0378 is hospital observation service, per hour.  We find that CPT code G0378 is not supported in the medical record. Specifically, this code is reported more than once on a 13x or 85x claim/bill type. This code was billed more than once and less than 8 units. This means the provider did not bill as required by the coding regulations. Based on this information, we decided that Medicare rules for coverage of the hospital observation services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital observation services coded G0378 provided from June 3, 2021 to July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on September 21, 2021.  You asked the Plan to waive the copayment for an office visit. You say that the office visit was just a physical and no copayment would be applied. The Plan denied your request. The Plan says an office visit was rendered and the copayment was properly fixed to 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 $10 copayment for each covered visit with your primary care provider.     You have been asked to pay a $10 copayment for an office visit. The office visit with your primary care provider falls within the Physician/Practitioner services, including doctor's office visits 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 an office visit provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wrist and hand orthosis (splints) provided on April 30, 2021.

You asked the Plan to waive the coinsurance for the splints. You say that the provider advised you that there would not be a copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 20% coinsurance for each durable medical equipment (DME) item, including splints. 

You have been asked to pay $81.11, which is 20% of the allowed amount for the splints ($405.53 allowed amount x 20% coinsurance = $81.11). The splints fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for wrist and hand orthosis (splints) provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Sanexas therapy with nutripharmaceutical blend injections provided on July 26, 2021.  You asked the Plan to pay for the Sanexas therapy with nutripharmaceutical blend injections. You say that you would like reconsideration because this service was medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the billed services are non-covered per Medicare.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that CPT codes G0283, 96372, 97112, J2490, J3411, J3415, J7999 and 97016 are not supported in the record. Specifically, after review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State. Additionally, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of the Sanexas therapy with nutripharmaceutical blend injections have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas therapy with nutripharmaceutical blend injections provided on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided from March 12, 2021, to September 12, 2021.  You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that your delivery driver informed you that there were no copayments. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 20% coinsurance for durable medical equipment (DME), including oxygen equipment.    Item Allowed Amount 20% Coinsurance Oxygen Concentrator - March 12, 2021 $72.84 $14.57 Equipment Rental - March 12, 2021 $31.85 $6.37 Oxygen Concentrator - April 12, 2021 $72.84 $14.57 Equipment Rental - April 12, 2021 $31.85 $6.37 Oxygen Concentrator - May 12, 2021 $72.84 $14.57 Equipment Rental - May 12, 2021 $31.85 $6.37 Oxygen Concentrator - June 12, 2021 $72.84 $14.57 Equipment Rental - June 12, 2021 $31.85 $6.37 Oxygen Concentrator - July 12, 2021 $86.45 $17.29 Equipment Rental - July 12, 2021 $34.06 $6.81 Oxygen Concentrator - August 12, 2021 $86.45 $17.29 Equipment Rental - August 12, 2021 $34.06 $6.81 Oxygen Concentrator - September 12, 2021 $86.45 $17.29 Equipment Rental - September 12, 2021 $34.06 $6.81 Total:  $156.06  You have been asked to pay $156.06, which is 20% of the allowed amount for the oxygen concentrator. The oxygen concentrator falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for an oxygen concentrator provided from March 12, 2021, to September 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray services coded 71045 provided on June 9, 2021.  You asked the Plan to pay for the chest 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, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view.     We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows that a similar radiology procedure was performed by a different provider on the same day. An additional modifier to indicate another physician repeated the procedure in a separate session is required. However, this modifier was not billed with this service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray services coded 71045 provided on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says it is the responsibility to bill the primary insurance payer before the secondary payer.  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 met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the primary payer in the decision they issued to you and advised you to bill the primary insurer directly for payment. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation care discharge day management coded 99217 provided on August 4, 2021.  You asked the Plan to pay for the observation care discharge day management. 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 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).  We find that CPT code 99217 is not supported in the medical record. Specifically, there is no qualifying initial or subsequent observation care services in the enrollee's claims history to support this discharge service. Based on this information, we decided that Medicare rules for coverage of the observation care discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the observation care discharge day management coded 99217 provided on August 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 home health physical therapy visits.

You asked the Plan to pre-approve home health physical therapy. You say that home health physical therapy services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for home health care have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health physical therapy. Our reviewer says that the requested home health care is not medically reasonable and necessary. Our physician reviewer found that the documentation does not support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0480) provided on March 24, 2021, by an OON provider.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not authorized.    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 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 drug testing (G0480) provided on March 24, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedures codes 36215 and 75710) provided to
the enrollee on July 6, 2021.

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 the denied codes remain not supported.

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 the denied codes is:

CPT 36215:

Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a
vascular family

CPT 75710:

Angiography, extremity, unilateral, radiological supervision, and interpretation

We find that CPT codes 36215 and 75710 are not supported in the medical record. Specifically, these codes are
both inclusive to the more comprehensive procedure - CPT 36902. 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 services (procedures codes 36215 and 75710) provided to the enrollee on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a new continuous positive airway pressure (CPAP)
device.
You asked the Plan to provide coverage for a new CPAP device. You say that your device was recalled and
should be replaced by the Plan. The Plan denied your request. The Plan says this was a preventative recall on
the part of the provider. There is no indication that the provider was unable to provide you with a loaner
replacement device or are unable to repair your current device. We overturned the Plans denial for
continuity of care, stating this device was medically necessary for your use. The Plan requested a reopen and
stated that there was no documentation that the provider was not attempting to remedy your current device
which would have required the Plan to intercede on your behalf.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say Medicare covers
equipment only when it is reasonable and necessary. If the requested equipment serves the same purpose as
equipment already available to an enrollee, it is not considered reasonable and necessary. Medicare does not
fully replacement equipment that is less than five years old. While it is true that the Plan is required to provide
you with continuity of care and assist you when medically necessary equipment is required, the documentation
provided does not show that your current equipment was not usable. There is no documentation that the
provider was unable to loan or replace your current equipment. There is no documentation that you attempted
to work with the provider for replacement or repair without success prior to contacting the Plan. Therefore, we
decided that the Plan does not have to provide coverage for a new CPAP device.