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

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on August 16, 2019.You asked the Plan to pay for an electrocardiogram. You say that this service was medically necessary.The Plan denied your request. The Plan says this claim must be submitted to the enrollee's primary insurance.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has informed you this claim must be submitted to the enrollee's primary insurance. As the secondary insurer, the Plan cannot be held responsible for an electrocardiogram until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay foran electrocardiogram (93010) provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on November 7,
2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that this should be reprocessed and paid. The Plan
denied your request. The Plan says this service was not authorized.
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 has network providers
available who can provide 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 the nursing facility care (99308) provided on
November 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 50430 provided on March 27, 2019.You asked the Plan to pay for CPT code 50430. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services were not billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says modifiers -LT and -RT should be used whenever a procedure is performed on only one side. The file shows that this procedure was only performed on the right side and an appropriate modifier was not billed with CPT code 50430 in this case. Based on this information, we decided that Medicare rules for coverage of CPT code 50430 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 50430 provided on March 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the home health care services provided on December 3, 2019.
You asked the Plan to waive the deductible for the home health care services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received home health care services on the date of service at issue in this appeal. The Plan states the correct amount has applied towards your deductible per your contract with the Plan.
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 $750 deductible that must be met before the Plan will pay their share for Home health agency care. The item or service you asked the Plan to waive the deductible for falls within the benefit category Home health agency care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible that must be met before the Plan will pay their share for Home health agency care. This cost sharing is a contractual obligation that had not been met at the time the home health care services was received on December 3, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the home health care services provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided on June 20, 2019.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says authorization from the physician medical group prior to the admission was required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the inpatient admission. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided on June 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from June 16, 2019 through June 20, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you should not be liable to the cost-share because it should have been covered with the previous hospital stay.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on June 16, 2019 and discharged on June 20, 2019. You were asked to pay a $300 copayment per day from June 16, 2019 through June 19, 2019, days 1-4 of your inpatient hospital care. You were discharged on June 20, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $300 copayment per day required for days 1-5 for in-network inpatient hospital care. Thismeans 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 forinpatient hospital care from June 16, 2019 through June 20, 2019 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient mental health care provided from November 30, 2019 through December 3, 2019 by an in-network provider.You asked the Plan to waive the copayment forinpatient mental health care. You say that you did not agree with the hospital to make you stay.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient mental health care provided from November 30, 2019 through December 3, 2019. You were asked to pay a $330 copayment per day from November 30, 2019 through December 3, 2019, days 1-3 of your inpatient mental health care. You were discharged on December 3, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $330 copayment per day required for days 1-5 for in-network inpatient mental health care. 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 forinpatient mental health care provided from November 30, 2019 through December 3, 2019 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided on August 26, 2019.
You asked the Plan to pay for sedation services. You say that this should be paid. The Plan denied your request. The Plan says this code is not supported by the records.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, this code requires the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. The documentation does not indicate an observer other than the physician was present. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 21, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on June 12, 2019.
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 codes 95940, A4556, and A4215 are not supported.
The Plan must follow Medicare rules. 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 95940 and 95941. Code 95940 is a column II code with a
modifier indicator of 1 when billed with column I code 95941. Code 95940 was not billed with an appropriate
modifier to allow for separate payment.
The rules say that supplies, except for those identified as exclusions, are included in the global surgical
payment.
The provider submitted a claim for procedure codes A4556 (electrodes, per pair) and A4215 (sterile needle).
Payment for these supplies is included in the global surgical payment.
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 services rendered to the enrollee on June 12,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided from September 10 to September 20, 2019. You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says services could have been provided at a lower level of care. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that coverage criteria has not been met. Our physician reviewer found records show it was not expected this enrollee would improve in a reasonable period of time as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. 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 inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided from September 10 to September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the foot orthotics purchased from provider on November 2, 2019.You asked the Plan to reimburse you for the foot orthotics. You say that the Plan covered the orthotics in the past and should cover these.The Plan denied your request. The Plan says a provider must be participating with Medicare to receive payment and you were reimbursed in 2018 in error.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare.Therefore, we decided that the Plan does not have to reimburse you for the foot orthotics purchased from provider on November 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 19, 2019.You asked the Plan topay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 3, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 services. Our reviewer says that the services at issue in this were not supported by the medical records. Our physician reviewer found very little documentation accompanies the extensive drug screen. The indication for the testing is not clear from the comprehensive drug screen. There is not sufficient documentation to justify the test and the coding. The denial is upheld due to insufficient documentation to support the charge. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 3, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy visits, 60 minutes (90837) and psychotherapy visits, 45 minutes (90836) provided from February 9, 2019 to December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy visits, 60 minutes and psychotherapy visits, 45 minutes. You say that you have an established relationship with the provider and feel it is beneficial for you to continue to seek treatment from him. The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.
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 has network providers available who can provide 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 psychotherapy visits, 60 minutes (90837) and psychotherapy visits, 45 minutes (90836) provided from February 9, 2019 to December 3, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on September 30, 2019.You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay fo routpatient hospital services provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services from December 8, 2017 through December 10, 2017 by an out-of-network provider. You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says based on the information there was no evidence that the enrollee was unable to see a provider within the network or that seeing a provider within the network would not meet their needs. The Plan states there was no evidence that seeing a provider within the network would be detrimental to the enrollee's health or that it is medically necessary for the enrollee to see a provider outside of the network. 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 has network providers available who can provide 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 the services from December 8, 2017 through December 10, 2017 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the thorax (71250) provided on October 1, 2019. You asked the Plan to waive the copayment for the CT scan of the thorax. You say that you were not informed the copayment would be so high. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 CT scans. You have been asked to pay $189.98 (the allowed amount) for the CT scan of the thorax. 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 computed tomography (CT) scan of the thorax (71250) provided on October 1, 2019.