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

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on October 29, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment tests - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
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, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory tests provided by an out-of-network provider on February 4, 2021.
You asked the Plan to pay for the laboratory tests. You say that the participating doctor sends the specimens to process, the patient does not come to the lab. You say that the cost of the test, lab equipment and technicians is expensive, and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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 laboratory tests provided by an out-of-network provider on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for unlisted supplies and materials used in non-surgical procedures (99070) provided January 15, 2021.
You asked the Plan to pay for the medical supplies. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says CMS does not separately pay any provider or supplier other than the facility in the prospective (PPS) payment for services furnished to the beneficiary in preparation for, during, or following a procedure or surgery.
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 enrollee received the services during or in preparation for a procedure or surgery at the facility. Payment for this service would be included in the facility PPS payment. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for unlisted supplies and materials used in non-surgical procedures (99070) provided January 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93926) provided January 18, 2021.
You asked the Plan to pay for the duplex scan. You say that the scan was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 93926 is not supported in the medical record. Specifically, the claim was billed with diagnosis code R60.0, Localized edema. Insufficient medical records were provided to support this service for the diagnosis code billed. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (93926) provided January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 11, 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 procedure code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and this is not the appropriate code for these services. 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 testing services rendered on November 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of a bisphosphonate, IV Zoledronic acid, or Reclast, before they will approve the requested drug. You have not tried and failed the required drugs. The submitted documentation does not indicate why you cannot try the Plan's required drugs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for these servicesan electrocardiogram (93000) provided on May 26, 2020.You asked the Plan to pay for these servicesan electrocardiogram. You say that this should be covered as an in-network service.The Plan denied your request. The Plan says this is not separately payable.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 93000 has a bundled relationship with code 11200 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for these servicesan electrocardiogram (93000) provided on May 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a
participating ambulatory center on January 25, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this
copayment. 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 $175
copayment for outpatient surgery/in-network/ambulatory center.
You have been asked to pay a $175 copayment for an outpatient surgery. The correct copayment has been
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/innetwork/
ambulatory center 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
outpatient surgery provided by a participating ambulatory center on January 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services represented by code 99601 provided on July 20, 2020.
You asked the Plan to pay for code 99601. 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 and Medicare rules. In this case, CPT code 99601 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion services represented by code 99601 provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe removal of foreign body, external eye (65222) provided January 7, 2021.You asked the Plan to waive the cost share forthe removal of foreign body. You say that you would like this cost share waived.The Plan denied your request. The Plan says the claim has processed correctly as you had not yet met your deductible.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 a $203 deductible for diseases and injuries of the eye. The item or service you asked the Plan to waive the cost share for falls within the benefit category diseases and injuries of the eye. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible for diseases and injuries of the eye. This cost sharing is a contractual obligation that had not been met at the time the removal of foreign body was received on January 7, 2021.Therefore, we decided that the Plan does not have to waive the cost share forthe removal of foreign body, external eye (65222) provided January 7, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on January 26, 2021.
You asked the Plan to pay for Anesthesia for intraoral procedures, including biopsy (00170). You say that your dentist felt anesthesia services in an outpatient setting was medically necessary. The Plan denied your request. The Plan says anesthesia services are not covered for the dental procedures you had.
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 anesthesia services provided on January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the emergency room services (99284), insertion of stent in urinary duct (52332), and shock wave crushing of kidney stones and their subsequent removal (50590, 52310) provided February 1, 2021, to February 8, 2021.

You asked the Plan to waive the cost share for the emergency room services, insertion of stent in urinary duct, and shock wave crushing of kidney stones and their subsequent removal. You say that you believe you all these charges should be billed together. The Plan denied your request. The Plan says the cost shares for these services have processed correctly.

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 $90 co-payment for emergency room services and a $350 co-payment for outpatient surgical services.

You have been asked to pay a total cost share of $790 for the emergency room services, insertion of stent in urinary duct, and shock wave crushing of kidney stones and their subsequent removal ($350 co-payment plus 350 co-payment plus $90 co-payment). These services fall within the emergency room service and outpatient surgical services benefit categories. 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 cost share for the emergency room services (99284), insertion of stent in urinary duct (52332), and shock wave crushing of kidney stones and their subsequent removal (50590, 52310) provided February 1, 2021, to February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cytopathology services rendered on February 15, 2021 to February 16, 2021.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the submitted records do not support the billing of the -59 modifier for codes 88173, 88112, and 88104.The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  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 these services Our reviewer says that the submitted records do not support the billing of the -59 modifier for codes 88173, 88112, and 88104. Our coder reviewer found the medical records provided do not include sufficient documentation to support billing these services with a 59 modifier. In order to use this modifier, the medical records must include documentation to validate appropriate use of the modifier for the services performed. As the medical records do not include documentation to support billing 88173 26 59, 88112 26 59 and 88104 26 59, these services are not eligible for separate reimbursement.Welooked at this coder's review, the file, and Medicare rules. 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 forthe cytopathology services rendered on February 15, 2021 to February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 21, 2021.
You asked the Plan to pay for a telehealth visit. You say that Medicaid providers have been instructed to bill telehealth services with POS 12. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that providers should submit telehealth services claims using Place of Service (POS) 02-Telehealth to indicate they furnished the billed service as a professional telehealth service from a distant site.
We looked at the file and Medicare rules. The telehealth service at issue was not billed with POS 02. Based on this information, we decided that Medicare rules for coverage of a telehealth visit have not been met. Therefore, we decided that the Plan does not have to pay for a telehealth visit (99214) provided on January 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 31, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you do not want to pay the charges
if they do not apply toward your deductible. 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 $100
copayment for basic radiological services for outpatient hospital services.
You have been asked to pay a $100 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 March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the crown - porcelain fused to high noble metal (D2750) received February 15, 2021.
You asked the Plan to pay an additional amount for the crown. You say that you would not have agreed to the procedure if you were told up front about the copayment. The Plan denied your request. The Plan says the contract clearly states there is a $195 copayment for crowns.
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. You have been asked to pay a $195 copayment for the crown. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay an additional amount for the crown - porcelain fused to high noble metal (D2750) received February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on February 6, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. 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 anesthesia services rendered on February 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0426), and ground mileage (A0425) provided on February 3, 2021.
You asked the Plan to waive the copayment for non-emergency ambulance transportation, and ground mileage. You say that the hospital told you there would be no charge for the ambulance. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for non-emergency ambulance transportation, and ground mileage. The services at issue fall within the ambulance 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 non-emergency ambulance transportation (A0426), and ground mileage (A0425) provided on February 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora diagnostic colonoscopy provided by aparticipating ambulatory center on February 18, 2021.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that you do not agree with this copayment.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 $295 copayment for outpatient surgery/ambulatory surgical center. You have been asked to pay a $295 copayment for a diagnostic colonoscopy. The correct copayment has been applied to the services that were provided. A diagnostic colonoscopy falls within the outpatient surgery/ambulatory surgical center 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 fora diagnostic colonoscopy provided by a participating ambulatory center on February 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prolonged evaluation and management service before and/or after direct patient care; first hour (99358) rendered by the out of network (OON) provider on February 7, 2021.You asked the Plan to pay forthis service. You say that you are requestinga 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 forthe prolonged evaluation and management service before and/or after direct patient care; first hour (99358) rendered by the out of network (OON) provider on February 7, 2021.