Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 30, 2020 to August 19, 2020.

You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says the location where the services were provided was not reported.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. HHAs must report an additional line item with the same revenue code and date of service, reporting the location where services were provided with one of the three Q codes (Q5001, Q5002, and Q5009), one unit and a nominal covered charge (e.g., a penny).

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, these services were not billed with a Q code to report the location they were provided in. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 30, 2020 to August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an MRI provided on December 29, 2020.

You asked the Plan to waive the deductible for an MRI. You say that you disagree with the deductible charges and feel that you should owe a lesser amount. 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. Your contract with the Plan says that there is an $800 deductible for outpatient diagnostic tests and therapeutic services and supplies. 

You received an MRI on December 29, 2020. The record shows that you had paid $0 toward the $800 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $494.99. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an MRI was received on December 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an MRI provided on December 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) head or brain; without contrast material

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. Attached reports support level of service. Please reconsider for processing. The Plan denied your request. The Plan says the records do not support the service being performed more than once for this date of service by the servicing provider.

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 70450 is computed tomography (CT) head or brain; without contrast material.

We find that CPT code 70450 is not supported in the medical record. Specifically, the records reviewed do not support the service being performed by the rendering provider more than once for this date of service. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) head or brain; without contrast material.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on January 4, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the testing services. You say that the test was conducted based on the procedures ordered. The Plan denied your request. The Plan says prior authorization was not obtained as required.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on January 4, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that you got a compression stocking just last month and it was covered so you don't understand why it is not covered now. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost share for the pulmonary diagnostic tests provided on February 24, 2021.

You asked the Plan to waive the cost share for the pulmonary diagnostic tests. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says that the correct cost share has applied.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan did not provide the correct claim in dispute in order for us to verify the Plan applied your cost share correctly. The Plan included one claim for the incorrect date of service. Therefore, we decided that the Plan has to waive the cost share for the pulmonary diagnostic tests provided on February 24, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283) provided on December 19, 2020.
You asked the Plan to pay for an emergency room visit. You say that the enrollee had two emergency room visits on this date of service. The Plan denied your request. The Plan says this cannot be paid separately without a modifier.
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 99283 has a bundled relationship with code 99284 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99283) provided on December 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on January 6, 2021.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you disagree with the charges because the claims summary says that you owe nothing. 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 $70 copayment for diagnostic mammography provided at an outpatient hospital facility. 

You have been asked to pay a $70 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retrograde filling (D3430).

You asked the Plan to pre-approve the retrograde filling. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retrograde filling (D3430).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pharmacogenetic testing provided on October 28, 2020.

You asked the Plan to pay for pharmacogenetic testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says a panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

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, pharmacogenetic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have to pay for pharmacogenetic testing provided on October 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on December 18, 2020.
You asked the Plan to pay for the services provided. You say that the lab performed the tests that were ordered by the referring physician. The Plan denied your request. The Plan says molecular genetic screening testing is not a benefit for the diagnoses listed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show the enrollee is being treated for a specific medical problem. The records do not show the testing at issue are part of a specific treatment strategy. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment supported crown (D6058) provided on January 13, 2021.
You asked the Plan to pay for the dental services. You say that your policy indicates that all crowns are covered at a 50% copayment up to the $2,500 allowance. You say that a plan representative confirmed that crowns are covered at 50% coinsurance. You also say that these services should be covered. The Plan denied your request. The Plan says implant related services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and the abutment supported crown (D6058) provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on December 14, 2020.

You asked the Plan to pay for the office visit. You say that the physician provided medically necessary services and the claim should be processed for payment. The Plan denied your request. The Plan says prior authorization was required but not 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 by an out-of-network provider on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on January 22, 2021.

You asked the Plan to pay for oral hygiene instructions. You say that you feel your dentist should be paid for this service. You say you cannot afford to pay for it as you are on a fixed income. The Plan denied your request. The Plan says this service is not covered under the Plan's supplemental dental 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.

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 oral hygiene instructions (D1330) provided on January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for an inpatient hospital stay provided from December 17, 2020, to December 22, 2020.

You asked the Plan to waive the co-payment for an inpatient hospital stay. You say that you disagree with the out-of-network 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for days 1-6 for inpatient hospital care.

You had an inpatient hospital stay from December 17, 2020, to December 22, 2020. Therefore, you are responsible to pay a $295 co-payment for days 1-5 (December 17, 2020, to December 21, 2020). $295 (co-payment) x 5 (inpatient days) = $1,475.

You have been asked to pay the total co-payment amount of $1,475 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 co-payment for an inpatient hospital stay provided from December 17, 2020, to December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 3, 2020.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. This claim was billed with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on August 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on January 4 to January 11, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the requested care was medically necessary for the enrollee. The Plan denied your request. The Plan says the correct copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $343 copayment for each day of days 1 to 4 of inpatient hospital care. The enrollee has been asked to pay $1,372, or a $343 copayment for each day of days 1 to 4 an inpatient hospital stay. An inpatient hospital stay falls within the "Inpatient hospital care" 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 an inpatient hospital stay on January 4 to January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services described by current procedural terminology (CPT) code 22853 provided on August 10, 2020.
You asked the Plan to pay for CPT code 22853. You say that the medical records support the billing of CPT code 22853. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 22853.
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 22853 is Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). 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 CPT code 22853. Our reviewer says that the medical records do not support the billing of CPT code 22853. Our physician reviewer found the operative note does not describe insertion of anterior interbody device with screw fixation. The code 22853 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 22853 have not been met. Therefore, we decided that the Plan does not have to pay for the physician services described by current procedural terminology (CPT) code 22853 provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a monitoring device (A9279) provided on November 3, 2020.

You asked the Plan to pay for a monitoring device. You say that this is part of the enrollee's continuous positive airway pressure device. The Plan denied your request. The Plan says this was not billed with a valid code.

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 code A9279 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of a monitoring device have not been met. Therefore, we decided that the Plan does not have to pay for a monitoring device (A9279) provided on November 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 24, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges because you were not informed that you would owe a copayment. 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 $95 copayment for basic radiological services for outpatient hospital services. 

You have been asked to pay a $95 copayment for an ultrasound. An ultrasound falls within the outpatient hospital services 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 ultrasound provided on November 24, 2020.