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

We decided that the Plan does not have to pay for laboratory testing provided on December 22, 2020.
You asked the Plan to pay for lab test. You say that this testing is covered by Medicare and the Plan must reimburse no less than the amount that would have been paid for the service under Original Medicare. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this genetic testing was not ordered or approved by the treating physician.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-rays (D0220 x 2), crown (D2740),
and amalgam (D2160) provided from December 23, 2020, to December 30, 2020.
You asked the Plan to reimburse you for the dental services. You say that you were advised that your policy did
not cover out of network dental services. You say that you were informed that the plan would pay you back at
some rate as in network. You say that you were advised to just get the work done. You also say that you were
under the impression that you would be reimbursed for these services. The Plan denied your request. The Plan
says the provider in this case is out of network. The Plan says that dental services performed out of network are
not covered. The Plan also says that there is no record of a conversation regarding being reimbursed for out of
network dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse
you for the periapical x-rays (D0220 x 2), crown (D2740), and amalgam (D2160) provided from December 23,
2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on July 31, 2020.
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 office visit (99213) rendered by the out-of-network (OON) provider on July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752).
You asked the Plan to pre-approve the procedure.. You say that the procedure is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the intracept procedure in the setting of chronic low back pain due to degenerative disc disease, vertebrogenic pain, and Modic type changes have not been demonstrated in the peer-reviewed literature. The Plan states more research is needed to show safety and efficacy of the procedure.
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 the procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is 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 the procedure. have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899 and C9752).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport provided by American
Medical Response on May 13, 2021.
You asked the Plan to waive the copayment for ambulance transport. You say that you are on a fixed income
and would like to claim a hardship. 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 (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $200 copayment for each one-way ambulance transport.
The enrollee has been asked to pay a $200 copayment for ambulance transport. Ambulance transport falls
within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
ambulance transport provided by American Medical Response on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for a patient of extreme age (99100) provided on December 3, 2020.
You asked the Plan to pay for the anesthesia for a patient of extreme age. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator of B meaning that this service is always bundled into another service or procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure.) We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status
indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of the anesthesia for a patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for a patient of extreme age (99100) provided on December 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) and prophylaxis
(D1110) provided on July 6, 2021.
You asked the Plan to pay for the intraoral x-rays (D0220 and D0230) and prophylaxis (D1110). You say that
you are appealing the remaining balance. The Plan denied your request. The Plan says the claim processed
correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay the
allowed amount for the intraoral x-rays and prophylaxis when received from an out-of-network provider. You
are responsible for the charges above what the Plan pays. Therefore, we decided that the Plan does not have to
pay for the intraoral x-rays (D0220 and D0230) and prophylaxis (D1110) provided on July 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy sessions (CPT code
97164), for the enrollee.
You asked the Plan to pre-approve the physical therapy services. You say that the services are necessary. The
Plan denied your request. The Plan says the enrollee has been seen for numerous visits, and a walking and
exercise program does not require the continued skills of a physical therapist.
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 the physical therapy services. 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 the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee and
wife report no problem with the home exercise program back in July of 2021. The enrollee can transition to an
independent home exercise program.
The requested services are not part of a maintenance program, are the specialized skill, knowledge and
judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration. 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
physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve
ten (10) additional physical therapy sessions (CPT code 97164), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for cellulitis of lower extremities.
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare
criteria for IRF care.
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Unna boot strapping services coded 29580 provided on May 14, 2021.
You asked the Plan to pay for the Unna boot strapping 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 29580 is strapping; Unna boot.
We find that CPT code 29580 is not supported in the medical record. Specifically, this code requires an anatomical modifier to correctly process the claim. Review of the file does not support that this code was billed with an anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the Unna boot strapping services have not been met. Therefore, we decided that the Plan does not have to pay for the Unna boot strapping services coded 29580 provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on May 30, 2021.

You asked the Plan to pay for an office visit. You say that this was billed appropriately. The Plan denied your request. The Plan says this should be billed as an emergency room visit.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

The rules also state that any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department. 

We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that this service was provided in the emergency department and should be billed with an emergency department visit code. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on May 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on May 26, 2021.

You asked the Plan to waive the coinsurance for an office visit. You say that you were told that you would not have any copayments for your PCP (primary care provider). 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for services received from a primary care provider. 

You have been asked to pay $19.51, which is 20% of the allowed amount for primary care physician services ($97.55 allowed amount x 20% coinsurance = $19.51). An office visit 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 coinsurance for an office visit provided by Terrance Johns, MD, on May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy.

You asked the Plan to pre-approve out-of-network physical therapy. You say that you are out-of-state, and you do not drive. You say that you need physical therapy after surgery. The Plan denied your request. The Plan says there is no medical need to do physical therapy out-of-area and in-network providers are available when you return to the network area.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve out-of-network physical therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 0031U, 0032U, 81225, 81240, 81241, 81291, 81401, 81226, 81227, 81230, 81231, 81328, 81355, and 81479 provided on May 7, 2020.

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 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. 

We find that CPT codes 0031U, 0032U, 81225, 81240, 81241, 81291, 81401, 81226, 81227, 81230, 81231, 81328, 81355, and 81479 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Therefore, codes 0031U, 0032U, 81225, 81240, 81241, 81291, 81401 are not payable.

If a laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. This means that codes 81226, 81227, 81230, 81231, 81328, 81355, 81479 are not payable. 

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 0031U, 0032U, 81225, 81240, 81241, 81291, 81401, 81226, 81227, 81230, 81231, 81328, 81355, and 81479 provided on May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), complete series of x-rays (D0210) and bitewing x-rays (D0274) provided on April 26, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental care. You say that you chose this plan because your dental provider was in the network at the time. You never received any notification that the provider changed their network status, and you should be reimbursed for these services. The Plan denied your request. The Plan says this provider is not part of the Plan's dental network. Out-of-network dental care is not covered by your benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's contract says that dental services must be received from an in-network provider. 

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), complete series of x-rays (D0210) and bitewing x-rays (D0274) provided on April 26, 2021, by an out-of-network provider.

Your complaint about a potential miscommunication or change in your provider's network status is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injections (CPT code(s): 64495,
64494, 64493) for the enrollee.

You asked the Plan to pre-approve the injections. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says there is no documentation as to why radiofrequency ablation is not
medically appropriate for 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 injections. Our physician reviewer
found the procedure is not medically necessary under Medicare rules because there is no documentation as to
why radiofrequency ablation is not medically appropriate.

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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve therapeutic facet joint injections (CPT code(s): 64495, 64494, 64493) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the biological materials to aid in soft and osseous tissue regeneration (D4265) provided on April 21, 2021.

You asked the Plan to reimburse you for the dental service. You say that you are fully aware that gum treatment is normally not a covered benefit. You say that you wanted to explain that you got it because a new bridge would be much more costly. The Plan denied your request. The Plan says biological materials to aid in soft and osseous tissue regeneration is not listed as a covered dental service.

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 biological materials to aid in soft and osseous tissue regeneration is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the biological materials to aid in soft and osseous tissue regeneration (D4265) provided on April 21, 2021.