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

We decided that the Plan does not have to pay for the bedside drainage bag (A4357), provided on June 14, 2021.

You asked the Plan to pay for the bedside drainage bag You say that the item should be covered. The Plan denied your request. The Plan says the item was used in a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that the bedside drainage bag was used in a SNF or hospital. When DME is furnished for use in a SNF during a covered Part A stay, the DME Regional Carriers (DMERCs) shall not make separate payment for DME, since the DME is already included in the payment that the SNF receives for the covered stay itself. Therefore, we decided that the Plan does not have to pay for the bedside drainage bag (A4357), provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided from January 1, 2021, through January 5, 2021.

You asked the Plan to pay for the critical care services. You say that you would like these services reprocessed based on the medical documentation submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation that has been submitted does not detail specifically the time that was spent performing critical care services. Without this information, the claim cannot be processed. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided from January 1, 2021, through January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal adjustment (D9951), provided on August 9,
2021.

You asked the Plan to pay for the occlusal adjustment. You say that the service was medically necessary. The
Plan denied your request. The Plan says this is not a covered 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 requested items or services are not
among those covered under this benefit. Specifically, this service is not listed in the Plan's benefit chart.
Therefore, we decided that the Plan does not have to pay for the occlusal adjustment (D9951), provided on
August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laminectomy/discectomy (0275T).

You asked the Plan to pre-approve the laminectomy/discectomy. You say that you would like reconsideration
because this procedure is medically necessary and covered by Medicare. The Plan denied your request. The
Plan says the facility requested is not listed as a location for this procedure.

The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar
Decompression (PILD) will be covered by Medicare when provided in a clinical study under section
1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the laminectomy/discectomy have not been met. Specifically, the requested facility is not listed as
a location for this study or procedure. Therefore, we decided that the Plan does not have to pre-approve a
laminectomy/discectomy (0275T). Of note, the Plan has provided redirection for facilities which are listed as
locations for the requested procedure. Please contact the Plan for further information regarding these facilities.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on April 27, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that the device was medically necessary. The Plan denied your request. The Plan says The 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. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on April 27, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer must be billed first.

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 directed the provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 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 services provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2331) provided on July 27, 2021.
You asked the Plan to pay for the dental service. You say that you consulted your dentist about the dangerous wear on your 2 teeth. You say that you were advised the services would be considered a filling and therefore be covered. You also say that this service should be covered. The Plan denied your request. The Plan says there is an annual maximum benefit of $500 for covered dental services every year. The Plan also says that the annual maximum benefit has been exceeded.
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 and fillings are listed as covered, the annual maximum benefit has been exceeded. The record shows that the Plan paid $500 towards the services received on the date of service in this case. The Evidence of Coverage clearly states that any amount over the is your responsibility. Therefore, we decided that the Plan does not have to pay for the filling (D2331) provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on July 14, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that you paid the office visit and disagree
with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly,
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for x-rays.
You have been asked to pay a $25 copayment for an x-ray. An x-ray 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
an x-ray provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) and radiologic examination, spine, cervical; two or three views provided July 1, 2021.
You asked the Plan to pay for the chiropractic services. You say that the Plan has denied the initial visit with the chiropractor which is $150. You were told a chiropractor is considered a specialist. The x-ray copay should have been $35, not $150. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
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 outpatient office visit (99203) and radiologic examination, spine, cervical; two or three views provided July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (procedure codes 80307 and G0483) provided to the enrollee on May 4, 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 procedure code 80307 has not met the associated frequency relationship criteria.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found clinical information to support this request was not provided. There was no evidence of multiple drug class use or abnormal urine drug screening testing or other circumstances to justify this request. Therefore, the drug testing services will be considered not medically necessary based on the provided documentation. Also, there was no evidence that the frequency of testing was appropriate for this enrollee. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (procedure codes 80307 and G0483) provided to the enrollee on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure remains 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation system
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the OON provider on
May 29, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99213) rendered by the OON provider on May 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81479) provided on August 17, 2021.

You asked the Plan to pay for laboratory services. You say that this is a covered service. The Plan denied your request. The Plan says this was not ordered.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81479) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the anti-reflective coating and polycarbonate lenses
provided on July 13, 2021.

You asked the Plan to pay more toward the anti-reflective coating and polycarbonate lenses. You say that you
did not ask for the anti-reflective coating or the spherocylinder. You say that they were supposed to update
your lenses with the cheapest package. The Plan denied your request. The Plan says the benefit has been
exhausted.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers up to $100 every year for eyewear.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
additional coverage of the anti-reflective coating and polycarbonate lenses have not been met. Specifically, the
Plan paid $100 toward the lenses, which exhausted your benefit. Therefore, we decided that the Plan does not
have to pay more toward the anti-reflective coating and polycarbonate lenses provided on July 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination provided on April 25, 2021.
You asked the Plan to pay for a radiologic examination. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on April 15, 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 a radiologic
examination provided on April 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the porcelain crown (D2740) and core build up
(D2950) provided on July 19, 2021
You asked the Plan to reimburse you for the dental services. You say that you submitted a claim and receipt of
payment for reimbursement of $456 for 2 separate dates of service. The Plan denied your request. The Plan
says the dental plan offered is a discount plan that does not include claim payments.
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 and the services are listed as covered,
there are copayment amounts that apply. These are a contractual obligation you agreed to when you enrolled in
the Plan's dental coverage. Therefore, we decided that the Plan does not have to reimburse you for the
porcelain crown (D2740) and core build up (D2950) provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 19,
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 procedure code 80307 has not met the associated frequency relationship criteria.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the provided records do not meet the criteria set out in the Medicare guidelines.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services provided to the enrollee on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this procedure received FDA clearance in the summer of 2016. The Plan denied your request. The Plan says there is little evidence in the medical literature to suggest that this is an appropriate procedure for the enrollee's back pain.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found despite FDA clearance indicating that the procedure is not harmful, more research is needed to show efficacy for back pain. This is still considered experimental. 

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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are appealing this bill. 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. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 16, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 19, 2021.

You asked the Plan to pay for the dental service. You say that this was an emergency situation. You say that an exception should have been made. You also say that you would like this to be paid. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on July 27, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 19, 2021.