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

We decided that the Plan does not have to reduce the copayment for the chest x-ray you had at a freestanding radiological facility.

You asked the Plan to reduce the copayment for the chest x-ray. You say that you believe you should only have to pay 20% coinsurance for this x-ray. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this chest x-ray ($33.94) is less than your copayment obligation, you are responsible for the full allowed 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 basic radiological services at a freestanding radiological facility.

You have been asked to pay a $40 copayment for the chest x-ray. The chest x-ray falls within the basic radiological services at a freestanding radiological 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 reduce the copayment for the chest x-ray you had at a freestanding radiological facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral (complete series) x-ray images (D0210) and behavior management (D9920) provided on September 24, 2020 and September 25, 2020.

You asked the Plan to pay for the dental services. You say that you have not met your benefit maximum and these services should be covered. The Plan denied your request. The Plan says the comprehensive oral evaluation and the complete set of intraoral x-rays are covered services, but they will only be paid for once every three years. Claims from September 2019 show that you had both of these services only one year before. The benefit for these services has been exhausted, and therefore the Plan will not pay for the oral exam or the x-rays. The behavioral management is not a service that is covered by Medicare or by the Plan's supplemental dental benefit under any circumstances.

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 or were provided in a greater frequency than is allowed by the contract. The Plan provided documentation that they paid for a complete series of intraoral x-rays and a comprehensive oral exam in 2019. The contract clearly states that both of these services will only be covered once every three years. The behavior management is not listed as a service that is covered by this benefit.

Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral (complete series) x-ray images (D0210) and behavior management (D9920) provided on September 24, 2020 and September 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple repair of superficial wounds, routine venipuncture, CT of the head or brain, laboratory services, immunization administration, Tetanus vaccine, and ED visit provided on October 20, 2019.

You asked the Plan to pay for the medical services. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the simple repair of superficial wounds, routine venipuncture, CT of the head or brain, laboratory services, immunization administration, Tetanus vaccine, and ED visit provided on October 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the procedure is necessary for pain relief. The Plan denied your request. The Plan says there are not enough studies to show that the Vertiflex Superion device is better than regular treatment for the enrollee's problem.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 6, 2020, to August 7, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this copayment. 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 $393 copayment for each day for days 1-5 per admission. 

You have been asked to pay a $393 copayment for the inpatient hospital stay. The 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 copayment for the inpatient hospital stay provided from August 6, 2020, to August 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuroplasty and/or transposition of a cranial nerve with
current procedural terminology (CPT) code 64716 provided on July 8, 2020.

You asked the Plan to pay for CPT code 64716. You say that the medical records support the billing of CPT
code 64716. The Plan denied your request. The Plan says the medical records do not support the billing of CPT
code 64716.

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 64716 is Neuroplasty and/or transposition; cranial nerve
(specify).

We find that CPT code 64716 is not supported in the medical record. Specifically, the operative report does not
show that CPT code 64716 was documented. Neurolysis of the phrenic nerve, which is not a cranial nerve,
from the pericardium is described. Based on this information, we decided that Medicare rules for coverage of
CPT code 64716 have not been met. Therefore, we decided that the Plan does not have to pay for the
neuroplasty and/or transposition of a cranial nerve with current procedural terminology (CPT) code 64716
provided on July 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy.

You asked the Plan to waive the copayment for physical therapy. You say that you were told the copayment would be $0. You say that you would like to continue therapy with a $0 copayment. The Plan denied your request. The Plan says the claims reprocessed to only apply $40 copayment to each claim.

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 Medicare-covered therapy services in all places of service from an in-network providers.

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 19, 2020.

You asked the Plan to pay for the dental service. You say that you went to see an endodontist. You say that the doctors should be paid for seeing your. You also say that if it is not covered under your dental, then it should be covered under your regular insurance. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit for this service has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on October 19, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport.

You asked the Plan to waive the copayment for the ambulance transport. You say that you were admitted to the hospital for four days. The Plan denied your request. The Plan says the copayment 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 $200 copayment for Medicare-covered ambulance benefits for each one-way trip.

You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records do not support you were admitted to the hospital. 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 ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) provided September 14, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence the prescribing physician examined the enrollee

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed 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 pay for the knee orthosis and suspension sleeve. Our reviewer says that the items were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) provided September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing.

You asked the Plan to pay for genetic testing. You say that this testing was ordered as medically necessary and is a valuable tool when determining treatment for the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not a covered benefit for the diagnosis listed and was performed for screening purposes.

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 requisition form submitted indicates that this testing was requested to rule out the possibility of a diagnosis, not to directly impact the management or treatment of a specific condition. This type of genetic panel testing is not covered for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 15, 2020.

You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit.

You asked the Plan to waive the copayment for the urgent care visit. You say that neither you nor the insurance should pay this claim. 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 $50 copayment for each Medicare-covered urgently needed service.

You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows you received treatment. 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 urgent care visit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing (81479 and 81408) provided on November 19, 2020.

You asked the Plan to pay for the pharmacogenetic testing. You say that you would like reconsideration because this type of testing helps clinicians assess the efficacy of the treatment plan and the current level of care for chronic pain management and substance use disorders. The Plan denied your request. The Plan says to report a Comprehensive Genomic Profile service, providers should use CPT code 81479 once as a bundled code for the entire bundled multi-test panel at this time.

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, the 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 the pharmacogenetic testing (81479 and 81408) provided on November 19, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on August 14, 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 that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing/panels except the basic lipid panel.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on August 14, 2020.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sleep study provided by a participating hospital on October 5, 2020.

You asked the Plan to waive the copayment for a sleep study. You say that you had this done at home. You say that you should not have to pay this much. 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 $100 copayment for outpatient diagnostic tests/in-network/diagnostic procedures/outpatient hospital. 

You have been asked to pay a $100 copayment for a sleep study. Since sleep study results were analyzed by a participating hospital, the correct copayment has been applied. A sleep study falls within the outpatient diagnostic tests/in-network/diagnostic procedures/outpatient hospital 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 sleep study provided by a participating hospital on October 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on September 27, 2020 and November 10, 2020.

You asked the Plan to waive the copayments for the ambulance rides. You say that you are low-income and should not have to pay these bills. 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 $250 copayment for each one-way Medicare-covered ambulance transport for in- and out-of-service areas. 

You have been asked to pay a $250 copayment for each of the ambulance rides. The ambulance rides 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 copayments for the ambulance rides provided on September 27, 2020 and November 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (G0156) provided from July 20, 2020, to July 24, 2020.

You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied your request. The Plan says records for this service have not been 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. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home health or hospice settings, each 15 minutes. 

We find that CPT code G0156 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of home health services being performed. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services (G0156) provided from July 20, 2020, to July 24, 2020.