Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the blepharoplasty and anesthesia provided on March 10, 2020.

You asked the Plan to pay additionally for the blepharoplasty and anesthesia. You say that you are being billed by the provider. The Plan denied your request. The Plan says the provider was paid the Medicare allowable.

The Plan must follow Medicare rules. Medicare rules say that non-contract providers must accept as payment in full payment amounts applicable in Original Medicare. 

We looked at the file and Medicare rules. The provider was paid the Medicare allowable. Therefore, we decided that the Plan does not have to pay additionally for the blepharoplasty and anesthesia provided on March 10, 2020.

Please note: Our decision is solely regarding whether additional payment is due from the Plan and does not imply you can be held financially liable for these charges. Since the provider is billing you in excess of the Medicare allowed amount, you may wish to contact them to inform them you have a Medicare Advantage plan. If you continue to be billed, you may wish to report this to the CMS Regional office, 312-353-7180.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on
November 5, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services provided are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain
indications.

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36523
to support their denial. However, LCD L36139, L36129 and L36523 are not valid for the provider's billing
state of Arkansas. Therefore, we are unable to use LCD L36139, L36129 and L36523 to substantiate our
decision.

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that
the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the
cardiovascular risk assessment testing provided on November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pathology examination of tissue (88305) provided on February 8, 2021, by an out of network (OON) provider.

You asked the Plan to pay for a pathology exam. You say that the provider took the specimen at their office and sent them to your laboratory for analysis. The Plan denied your request. The Plan says services were provided 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a pathology examination of tissue (88305) provided on February 8, 2021, by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay provided January 18, 2021 to February 5, 2021.
You asked the Plan to waive the copayment for the SNF stay. You say that you are getting two bills from the nursing home, one for $280 and one for $100. You have always paid $15 a day for your SNF stays and want the same rate for these two stays. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 per day for days 1-20 of a benefit period.
You have been asked to pay $380 ($20 x 19 days) for the SNF stay. The SNF stay falls within the Skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) stay provided January 18, 2021 to February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27365) provided August 18, 2020.

You asked the Plan to pay for the surgical services.. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT codes 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 27365 is radical resection of tumor, from the femur or knee. 

We find that CPT code 27365 is not supported in the medical record. Specifically, no operative report detailing this procedure was included in the documentation provided. Based on this information, we decided that Medicare rules for coverage of the surgical services. have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27365) provided August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2020.
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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214) provided on February 3, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you should not have to pay a copayment. You also say that you would like this claim reviewed to see if there is an exception to coverage. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 physician/practitioner services, including doctor's office visits.

You have been asked to pay a $10 copayment for an office visit. The EOC confirms $10 is the required copayment for this service. The records show that this was not a routine eye exam but in fact an office visit. 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 copayment for an office visit with a specialist (99214) provided on February 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection provided on December 4, 2020.

You asked the Plan to waive the coinsurance for the injection. You say that you should not have to pay this amount. The Plan denied your request. The Plan says that cost-sharing is a contractual obligation and cannot be waived.

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 Medicare-covered Part B drug. 

You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare-covered Part B drug 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 the aflibercept injection provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray
(D0330) provided on March 4, 2021.
You asked the Plan to pay for the dental services. You say that you strongly believe that errors were made in
billing. You say that you should not have been charged $300. You also say that seeking another dentist saved
your tooth and unnecessary root canal. The Plan denied your request. The Plan says 1 limited oral evaluation is
covered per plan year. The Plan says that 1 panoramic x-ray is covered every 3 plan years. The Plan also says
that the frequency limits have 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 services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for a limited oral evaluation and
panoramic x-ray that you received on February 3, 2021. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on March 4, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on January 13, 2021, to
January 14, 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 procedure code 99291 is 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 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, there is no documentation of
30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered on January 13, 2021, to January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy (31267, 31276) provided October
12, 2020.
You asked the Plan to pay for the nasal/sinus endoscopy. You say that you would like these claims reprocessed
for medical necessity. The Plan denied your request. The Plan says the submitted codes are not supported in the
medical records submitted.
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 31259 is nasal/sinus endoscopy, surgical, with maxillary
antrostomy; with removal of tissue from maxillary sinus and 31276 nasal/sinus endoscopy, surgical, with
frontal sinus exploration, including removal of tissue from frontal sinus, when performed.
We asked our coder 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 nasal/sinus endoscopy. Our reviewer
says that the codes submitted are not supported by the medical records submitted. Our physician reviewer
found that the medical records provided does not include sufficient documentation to validate that a nasal/sinus
endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when
performed was the service that was performed on October 12, 2020, therefore, this procedure cannot be
verified. In addition, the medical records provided do not include sufficient documentation to validate that a
Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus was
performed bilaterally on October 12, 2020, as indicated by the 50 modifier billed with this service. Therefore,
this service cannot be verified.
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 nasal/sinus endoscopy have not been met. Therefore, we decided that the
Plan does not have to pay for the nasal/sinus endoscopy (31267, 31276) provided October 12, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431), and an unspecified
preventive procedure (D1999) provided on March 10, 2021.
You asked the Plan to pay for an adjunctive pre-diagnostic test, and an unspecified preventive procedure. You
say that you should not be responsible for the charges. The Plan denied your request. The Plan says the services
at issue are not covered benefits.
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 an
adjunctive pre-diagnostic test (D0431), and an unspecified preventive procedure (D1999) provided on March
10, 2021.
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 for the enrollee.
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 the enrollee has no complex medical needs that require intensive rehabilitation.
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The patient was admitted for stroke and congestive heart failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on March 11, 2021.
You asked the Plan to waive the copayment for these services. You say that the Plan should pay for the injections. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting.
Review of the file shows that you received outpatient surgical services on March 11, 2021. You have been asked to pay a $300 copayment for these services. These services fall within the surgery performed in an outpatient hospital setting 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 outpatient surgical services rendered on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device (E0675) segmental gradient pressure pneumatic appliance (E0673) provided January 14, 2021.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that the DME equipment was prescribed by the doctor and was issued to the enrollee for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. 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 must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. In this case, 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. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pay for pneumatic compression device (E0675) segmental gradient pressure pneumatic appliance (E0673) provided January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on August
11, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15
copayment for each covered lab service.
Review of the file shows that you received outpatient laboratory services on August 11, 2020. You have been
asked to pay a $15 copayment for these services. These services fall within the covered lab service 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 laboratory services rendered on August 11,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided on February 26, 2021.
You asked the Plan to waive the copayment for the outpatient surgical services. You say that this is too much for you to pay and that insurance is not paying enough. The Plan denied your request. The Plan says that the benefit 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 $350 copayment for outpatient surgery provided at an outpatient hospital facility. You have been asked to pay a $350 copayment for the outpatient surgical services. The outpatient surgical services fall within the outpatient surgery provided at an outpatient hospital facility 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 outpatient surgical services provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ScoliSmart Activity Suit provided on January 11, 2021.
You asked the Plan to pay for this item. You say that this should not be considered exercise equipment. The Plan denied your request. The Plan says that this is excluded from coverage.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the ScoliSmart Activity Suit provided on January 11, 2021.