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

We decided that the Plan does not have to pre-approve Ecotric Starfish portable folding electric bike.
You asked the Plan to pre-approve the electric bike. You say that the electric bike would be considered rehab equipment for you due to your many disabilities. The Ecotric Starfish would be more cost effective than a mobility scooter which you would not be able to operate due to your many disabilities. The Plan denied your request. The Plan says the requested bike is not designed to be used in the home and is not covered by Medicare.
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 pre-approve Ecotric Starfish portable folding electric bike.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided January 2, 2021 to January 9, 2021.

You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a %15 coinsurance for inpatient care. 

You have been asked to pay a %15 coinsurance for the inpatient hospital care. The inpatient hospital care falls within the inpatient 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 coinsurance for inpatient hospital care provided January 2, 2021 to January 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest rendered on February 23, 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 71260 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71260 (CT chest) and 71275 (CT angiography chest). Code 71260 is a column II code with a modifier indicator of 1 when billed with column I code 71275.
Code 71260 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest rendered on February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for outpatient rehabilitation services provided from December 30, 2020, to March 3, 2021.

You asked the Plan to waive the co-payments for outpatient rehabilitation services. You say that you disagree with the charges because you were not aware that you would owe a co-payment and feel that the Plan should be responsible for the 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 $40 co-payment for outpatient rehabilitation services.

You received outpatient rehabilitation services from December 30, 2020, to March 3, 2021, for a total of 11
visits. Therefore, you are responsible to pay a $40 co-payment per each visit. The total amount you owe is: $40 (co-payment) x 11 (outpatient rehabilitation services) = $440.

You have been asked to pay the total co-payment amount of $440 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 co-payments for outpatient rehabilitation services provided from December 30, 2020, to March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous passive motion (CPM) device rendered from January 31, 2020 to February 20, 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 must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. The enrollee has not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pay for the continuous passive motion (CPM) device rendered from January 31, 2020 to February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).

You asked the Plan to preapprove the CGM. You say that you do not want or are unable to utilize a test involving pricking a finger. The Plan denied your request. The Plan says you do not meet coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided
on February 2, 2021.
You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you received
physical therapy one time and one of the therapies should not be charged. 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 $40
copayment for outpatient rehabilitation services.
The medical records show that you received outpatient rehabilitation services on February 2, 2021. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on February 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standing table with accessories.
You asked the Plan to pre-approve standing table. You say that this item is essential for the enrollee so that she
can continue to bear weight on the long bones of her lower extremities. The Plan denied your request. The Plan
says the denial of authorization for this item is correct, because Medicare considers this a comfort/convenience
item that is not primarily medical in nature and not covered.
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 pre-approve a standing table with accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for one unit of discarded carboplatin (J9045-JW) provided on December 17, 2020.
You asked the Plan to pay for discarded carboplatin. You say that this was submitted with the correct national drug code (NDC) information. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that contractors shall require the use of the modifier JW to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded. We looked at the file and Medicare rules. 4 units of the drug at issue were billed as used, and 1 unit was billed as discarded. However, the submitted NDC code shows that the drug at issue is supplied in a vial of 12 units. The billed units do not correspond to the number of units in the vial. Based on this information, we decided that Medicare rules for coverage of discarded carboplatin have not been met. Therefore, we decided that the Plan does not have to pay for one unit of discarded carboplatin (J9045-JW) provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical office visit related to tooth pain provided on January 14, 2021.
You asked the Plan to pay for the office visit. You say that you were not aware this service would not be covered. The Plan denied your request. The Plan says this service is excluded from coverage for your diagnosis.
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. Evaluation by a physician for tooth pain is considered a dental service as it is care/treatment of the teeth or supporting structures. Though your Plan does cover some dental services, these must be provided by a network dentist. Therefore, we decided that the Plan does not have to pay for the medical office visit related to tooth pain provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulation, neuromuscular re-education, physical therapy treatments, and ultraviolet light therapy provided from February 2, 2020, through December 2, 2020 by an out of network (OON) chiropractor.
You asked the Plan to pay for the various OON services provided by a chiropractor. You say that you feel that this should be covered out of network because the network does not have any provider who can provide the care you receive from this chiropractor. You feel that if you are not reimbursed that you will be unable to continue this treatment that is working well for you. The Plan denied your request.
The Plan says the Medicare-covered chiropractic services you have received are available from network providers. The other services are not covered when provided by a chiropractor.
The only service from a chiropractor that Medicare covers is manual manipulation of the spine to correct a subluxation. Medicare rules say that plans can require enrollees to get Medicare-covered services 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 Medicare-covered chiropractic services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The other services provided would not be covered whether provided by a in or out of network chiropractor. 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 chiropractic manipulation, neuromuscular re-education, physical therapy treatments, and ultraviolet light therapy provided from February 2, 2020, through December 2, 2020 by an out of network (OON) chiropractor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office/outpatient visit (99202) received February 9, 2021.

You asked the Plan to pay for the office/outpatient visit (99202). You say that this was a routine exam. The Plan denied your request. The Plan says the provider billed this exam with a diagnosis of cataracts. Therefore, this was not a routine exam.

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 routine eye exams when received through a Plan network vision care vendor. 

We looked at the file and the Plan's rules. The provider billed this exam with a diagnosis of cataracts. This means the requested service is a Medicare-covered, not a routine, eye exam. Medicare-covered eye exams, for the diagnosis and treatment of diseases of the eye, require a $40 copayment. Based on this information, we decided that the correct cost share for the office/outpatient visit (99202) was applied to this claim. Therefore, we decided that the Plan does not have to pay for the office/outpatient visit (99202) received February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the medical eye exam and the ophthalmic
biometry provided on January 29, 2021.

You asked the Plan to waive the copayments for the medical eye exam and the ophthalmic biometry. You say
that you were told by the provider that there would be no cost. 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 a $35 copayment for each in-network Medicare-covered exam to treat an eye condition and a $90 copayment for each covered diagnostic procedure or test at a network doctor's office. 

You have been asked to pay a $35 copayment for the medical eye exam and a $23.11 copayment, which is less than the standard amount, for the ophthalmic biometry. The medical eye exam falls within the "Vision care - Medicare-covered" benefit category. The ophthalmic biometry 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 copayments for the medical eye exam and the ophthalmic biometry provided on January 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on February 6, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that you did not know that your copayment would be $60. You say that if you had known it would cost this much you would not have had the ultrasound done. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for outpatient diagnostic tests/in-network/ultrasound. 

You have been asked to pay a $60 copayment for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/in-network/ultrasound 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 by a participating provider on February 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from January 7,
2021, through January 28, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that you were told it was approved
and you now have a bill for $280. The Plan denied your request. The Plan says the copayments 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 $40
copayment for each Medicare-covered physical and speech therapy service.

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $280 ($40/visit x 7 visits = $280). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from January 7, 2021, through January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 8, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The laboratory testing at issue in this appeal 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 provided on December 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the emergency room service provided on February 12, 2021.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

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 $100 co-payment for Medicare-covered emergency and post stabilization of care services.

You have been asked to pay a $100 co-payment for the emergency room service provided. 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 the emergency room service provided on
February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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 looked at the file, the Plan's contract and Medicare rules. If a laboratory assays two or more genes in a patient 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 HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patient's medical record must reflect that the service billed was reasonable and necessary. 

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. 

In this case, the medical records provided do not confirm that the labs were billed correctly. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 23, 2020.