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

We decided that the Plan does not have to waive the copayment for laboratory services provided on December
23, 2020.
You asked the Plan to waive the copayment for the laboratory services. You say that you had never heard of
these doctors and you did not go in for an appointment. You say that you are not paying the bill. 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 $20
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays and ultrasounds.
You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that laboratory services were 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 copayment for laboratory services provided on December 23, 2020.
Your complaint about someone using your Medicare is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of arm splint rendered on August 14, 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 29105 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 29105 is application of long arm splint (shoulder to hand). We find that CPT code 29105 is not supported in the medical record. Specifically, there is no documentation of application of a long arm splint (shoulder to hand). 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 application of arm splint rendered on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services provided on February 10, 2021 by an out of network (OON) provider.

You asked the Plan to pay for optometry services. You say that these services were provided in good faith. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 optometry services provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for inpatient hospital services provided February 6, 2021, to February 12, 2021.

You asked the Plan to waive the co-payment for inpatient hospital services. You say that you believe you do not owe a co-payment. The Plan denied your request. The Plan says the co-payment has processed correctly in this case.

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 $365 co-payment each day for days 1-5 and a $0 co-payment each day for days 6+ for inpatient hospital care.

You have been asked to pay a total cost share of $1825 for the six days of inpatient hospital care (6 inpatient days x $365 co-payment). The services provided fall 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 inpatient hospital services provided February 6, 2021, to February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingivectomy or gingivoplasty (D4211), and an unspecified
preventive procedure (D1999) provided on October 21, 2020.
You asked the Plan to pay for gingivectomy or gingivoplasty, and an unspecified preventive procedure. You
say that you cannot afford the payment and you want the Plan to pay for these services. The Plan denied your
request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
gingivectomy or gingivoplasty (D4211), and an unspecified preventive procedure (D1999) provided on
October 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided during surgery performed
on January 28, 2021.
You asked the Plan to pay for self-administered drugs. You say that you did not agree to the services at issue.
The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided
during surgery performed on January 28, 2021.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided from November 19, 2019, to January 21, 2021.
You asked the Plan to waive the cost shares for the services provided. The Plan denied your request. The Plan says the claims processed 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).
The file shows that you received observation services from November 11, 2019, to November 19, 2019. You were charged a $350 copay. The services fall within the outpatient hospital services benefit category.
You received skilled nursing facility care from December 1, 2019, to December 11, 2019. You were charged a $165 copay for 3 days of care. The services fall within the skilled nursing facility services benefit category.
You received physical and occupational therapy from December 12, 2019, to December 31, 2019. You also received occupational therapy services from December 9, 2020, to December 10, 2020. You were charged a $25 copay per provider for each date of service.
You received a magnetic resonance imaging (MRI) test on March 3, 2020. You have been asked to pay a $200 copay for the MRI. The services fall within the outpatient diagnostic tests benefit category.
You received specialist office visits on March 9, 2020, October 20, 2020, and December 9, 2020. You were charged a $45 copay for each date of service. The services fall within the physician services benefit category.
You received podiatry services on March 20, 2020. You were charged a $25 copay. The services fall within the podiatry services benefit category.
You received a nerve study on October 28, 2020, and a chest x-ray on November 13, 2020. You were charged a $45 copay for each test. The services fall within the outpatient diagnostic tests benefit category.
You received cast supplies on December 31, 2020, and January 21, 2020. You were charged a 20% coinsurance on each date of service. The services fall within the outpatient diagnostic tests and supplies benefit category.
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 shares for the medical services provided from November 19, 2019, to January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 11, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed 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. 

In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. 

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits with an out-of-network provider.

You asked the Plan to pre-approve out-of-network office visits. The Plan denied your request. The Plan says in-network providers are available.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visits with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the urgent care services rendered on May 10, 2020.

You asked the Plan to waive the co-payment for these services. You say that the receptionist applied the incorrect co-payment amount. The Plan denied your request. The Plan says the co-payment was applied 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 $40 co-payment for urgent care center services.

Review of the file shows that you received urgent care services on May 10, 2020. You have been asked to pay a $40 co-payment for these services. These services fall within the urgent care center 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-payment for the urgent care services rendered on May 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the 2 simple extractions (D7140), the surgical extraction (D7210), and the immediate partial upper denture (D5221) provided on January 18, 2021.
You asked the Plan to waive the out of network cost share for the dental services. You say that your regular dentist left. You say that these quoted services were performed by the dentist that replaced him. The Plan denied your request. The Plan says the claim was processed correctly. The Plan says that if you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan also says that out of network providers may bill you for any amount greater than the payment made by the Plan to the provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, dental services performed out of network may bill you for any amount greater than the payment made by the Plan to the provider.
CPT Code
Billed
Allowed
Difference
Plan Paid
Coinsurance
Your Responsibility
D7140
$143
$76
$67
$34.20
$41.80
$108.80
D7140
$143
$76
$67
$34.20
$41.80
$108.80
D7210
$250
$144
$106
$64.80
$79.20
$185.20
D5221
$955
$955
$0
$238.75
$716.25
$716.25
TOTAL:
$240
$879.05
$1,119.05
This is a contractual obligation that you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the out of network cost share for the 2 simple extractions (D7140), the surgical extraction (D7210), and the immediate partial upper denture (D5221) provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interlaminar/interspinous process device surgery.

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 you need this surgery so you can spend the remaining years of life in less pain, be
independent at home and improve your overall quality of life. The Plan denied your request. The Plan says
there is lack of evidence to support interspinous spacer devices as safe and effective as the gold standard of
surgical decompression.

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 interlaminar and interspinous
devices remain experimental. More research is needed to show safety and efficacy of the device. Open
laminectomy remains the gold standard procedure.

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
interlaminar/interspinous process device surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on December 15, 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 J0280 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 J0280 is injection, aminophylline, up to 250 mg.
We find that CPT code J0280 is not supported in the medical record. Specifically, there is no documentation of
injection of up to 250 mg of aminophylline for the billed date of service. 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 injection rendered on December 15, 2020.
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
July 22, 2020.

You asked the Plan to pay for the office visit. You say that you requested enrollment with the Plan but didn't
receive any response. You say that you are losing out on reimbursement and the claim should be processed at
the contracted rate. 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 July 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services rendered by a physical therapy assistant (PTA) on May 8, 2020.
You asked the Plan to pay for the PTA services. You say that your office provides a range of services with physician oversight to patients in their homes. You state that you are not a home health agency but provide physician oversight of services rendered in the home. The Plan denied your request. The Plan says this is not the correct code for these services. There is an appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0157) for the billed service.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA are not covered when incident to a physician or NPP service since the services must be supervised by a physical therapist.
In this case, a PTA provided the therapy services at issue. These services were billed, not by a supervising therapist, but by a nurse practitioner. As these are being billed as incident to a NPP's services, payment cannot be made. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services rendered by a physical therapy assistant (PTA) on May 8, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for tissue transfer (14301, 14302) provided on September 21, 2020.

You asked the Plan to pay for tissue transfer. You say that these codes are supported. The Plan denied your request. The Plan says that these procedures are not documented.

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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (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 tissue transfer. Our reviewers says that the billed codes are supported in the records. Our physician reviewer found the operative note indicates that adjacent tissue transfer of 95 square centimeters was performed through the use of back cuts. The operative report describes tissue transfer and rearrangement rather than complex wound closure because separate back cut incisions were made. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tissue transfer have been met. Therefore, we decided that the Plan has to pay for tissue transfer (14301, 14302) provided on September 21, 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.