Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic injections rendered on December 26, 2019 to December 29, 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 96376 and 96372 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 96376, 93306, 96372, and 96365. Code 96376 is a column II code with a modifier indicator of 1 when billed with column I code 93306. Code 96372 is a column II code with a modifier indicator of 1 when billed with column I code 96365. Codes 96376 and 96372 were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the therapeutic injections rendered on December 26, 2019 to December 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M) provided November 12, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CxBladder Detect (0012M, 0013M) is not an approved test. We looked at the file and Medicare rules. The service at issue is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M) provided November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for wound debridement provided from November 12, 2020, through January 21, 2021.
You asked the Plan to reduce the copayment for the wound debridement. You say that this was not surgery or a surgical service, they just changed the bandages. You say that you were expecting a $35 copayment. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your 2020 contract with the Plan clearly says that you must pay a $325 copayment per visit, per provider, per day for surgery performed in an in-network outpatient hospital setting. Your 2021 contract with the Plan clearly says that you must pay a $350 copayment per visit, per provider, per day for surgery performed in an in-network outpatient hospital setting
You have been asked to pay a total of $2,032.90 for the wound debridement.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
November 12, 2020
Wound Debridement
$336.23
$325
$325
November 19, 2020
Wound Debridement
$336.23
$325
$325
December 3, 2020
Wound Debridement
$336.23
$325
$325
December 10, 2020
Wound Debridement
$268.98
$325
$268.98
December 31, 2020
Wound Debridement
$268.98
$325
$268.98
January 7, 2021
Wound Debridement
$259.97
$350
$259.97
January 21, 2021
Wound Debridement
$259.97
$350
$259.97
TOTAL:
$2,032.90
The wound debridement falls within the "Outpatient hospital services" benefit category. Wound debridement is considered a surgical service. 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 wound debridement provided from November 12, 2020, through January 21, 2021.
Your complaint about feeling robbed 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient diagnostic services (36415, 82565, 84520, 70553, A9577) provided on December 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that it is clear that the services provided were medically necessary and provided promptly and at the appropriate level of care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient diagnostic services (36415, 82565, 84520, 70553, A9577) provided on December 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for IPACK Block provided on June 2, 2020.
You asked the Plan to pay for IPACK Block (64999). You say that the Plan should pay this claim. The Plan denied your request. The Plan says code 64999 should not be billed by an anesthesia practitioner.
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 the practitioner billing the code is not eligible to do so. A corrected claim is necessary. Based on this information, we decided that Medicare rules for coverage of IPACK Block (64999) have not been met. Therefore, we decided that the Plan does not have to pay for IPACK Block provided on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.

You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that a group 2 support surface is covered when specific criteria are met. 

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 a powered pressure-reducing air mattress. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria. The records do not document that you have multiple stage 2 pressure ulcers located on the trunk or pelvis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the $95 copayment and apply an $80 copayment for the diagnostic mammography provided on February 15, 2021.
You asked the Plan to waive the copayment for the diagnostic mammography. The Plan denied your request. The Plan says that the correct copayment has been applied to the claim.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information. Your contract with the Plan clearly says that you must pay an $80 copayment for Diagnostic Mammography. Therefore, we decided that the Plan has to waive the $95 copayment and apply an $80 copayment for the diagnostic mammography on February 15, 2021.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy.

You asked the Plan to pre-approve the additional physical therapy. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 the additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that PT can be generally accepted as specific and effective therapy for an ataxic gait; however, the records are insufficient to demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment for the enrollee in this case. It has not been established that the enrollee is participating in a maintenance program.

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 additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant, first 15 minutes of deep sedation/general anesthesia, and subsequent 15 minute increment of deep sedation/general anesthesia provided on September 15, 2020.
You asked the Plan to pay for the endosteal implant and deep sedation/general anesthesia services. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered.
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 the surgical placement of implant body: endosteal implant, first 15 minutes of deep sedation/general anesthesia, and subsequent 15 minute increment of deep sedation/general anesthesia provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the platelet rich plasma injections provided on June 9, 2020.

You asked the Plan to reimburse you for the platelet rich plasma injections (0232T). You say that you needed the injections for your knee pain. The Plan denied your request. The Plan says the service is not covered when performed for bilateral knee pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. You do not have a qualifying diagnosis. Based on this information, we decided that Medicare rules for coverage of the platelet rich plasma injections (0232T) have not been met. Therefore, we decided that the Plan does not have to reimburse you for the platelet rich plasma injections provided on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit for assessment and management of a patient (G0463) provided February 22, 2021.
You asked the Plan to waive the copayment for the clinic visit. You say that you were seeing your primary doctor so no copay charges should occur. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $20 copayment for all other Medicare covered outpatient hospital services for Outpatient hospital services. You have been asked to pay $20 copayment for the clinic visit. The clinic visit 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 hospital outpatient clinic visit for assessment and management of a patient (G0463) provided February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to make additional payment for the chest x-ray provided on October 19, 2020, the cardiology office consultation provided on December 2, 2020, the computed tomography (CT) scan of the thorax provided on December 7, 2020, and the echocardiogram and the nuclear stress test with regadenoson injection provided on December 15, 2020.

You asked the Plan to make additional payment for the medical services rendered. You say that you believe that due to COVID rules, all care must be covered by the Plan at 100%. The Plan denied your request. The Plan says the cost sharing waiver only applies to services for testing and diagnosing COVID-19. The Plan has decided to waive the charges for certain services that fall into this category. However, the remaining services do not meet the rules for the cost sharing waiver.

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 outlines the cost sharing related to certain medical services as noted in the Medicare rules section.

You have been asked to pay $12.67 for the chest x-ray from the out of network provider, which is 40% of the allowed amount for this procedure. You have been asked to pay a $40 copayment for the cardiology visit. This falls into the office consultations with a specialist benefit category.

You were also asked to pay $115.59 for the CT scan and $285 for the nuclear stress test imaging, which are both less than the applicable $325 copayments. A $40 copayment was assigned to the echocardiogram, which falls into the diagnostic procedures and tests benefit category. You were also asked to pay 20% of the allowed amount of the regadenoson which was injected during the nuclear stress test. This falls into the Medicare Part B prescription drugs benefit category.

Based on review of this information, we find 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 make additional payment for the chest x-ray provided on October 19, 2020, the cardiology office consultation provided on December 2, 2020, the computed tomography (CT) scan of the thorax provided on December 7, 2020, and the echocardiogram and the nuclear stress test with regadenoson injection provided on December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for pathology services (80053, 83036) provided February 8, 2021 to February 10, 2021.
You asked the Plan to waive the copayments for the pathology services. You say that the copayment should be waived. The Plan denied your request. The Plan says the copayment was correctly 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 $30 copayment for lab services billed by an outpatient hospital. You have been asked to pay a $30 copayment for each pathology service. The pathology services fall within the lab services billed by an 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 copayments for pathology services (80053, 83036) provided February 8, 2021 to February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 heavy duty wheelchair for the enrollee.
You asked the Plan to pre-approve a Group 2 heavy duty wheelchair. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for approval.
The Plan must follow Medicare rules. Medicare rules say that if a heavy duty PWC is provided and if the beneficiary's weight is outside the range listed (i.e., for heavy duty - 285 - 450 pounds, for very heavy duty - 428 - 600 pounds, for extra heavy duty - 570 pounds or more), it will be denied as not reasonable and necessary. We looked at the file and Medicare rules. The file indicates the enrollee's weight is outside of the range for a heavy duty wheelchair. Based on this information, we decided that Medicare rules for coverage of a Group 2 heavy duty wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 heavy duty wheelchair for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection provided on August 4, 2020.
You asked the Plan to waive the copayment for the epidural injection. You say that you were unable to get the injection because they couldn't reach a doctor to administer the medication. You say that you were informed you would only be charged for the second day so this copayment is a mistake. 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 $285 copayment for each covered surgery or observation room service at an in-network outpatient hospital. You have been asked to pay a $285 copayment for the epidural injection. The epidural injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that you were prepped for the procedure. 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 epidural injection provided on August 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on January 6, 2021.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you already met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $102.26. The total amount you are being asked to pay is $20.45 ($102.26 x 20% = $20.45). The correct copayment has been applied to the equipment that was provided. Durable medical equipment falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on January 6, 2021 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim 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 the referring provider is out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plansays 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 thePlan does not have to pay forphysician services provided on January 6, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for adding a tooth to an existing partial denture (D5650 x2).
You asked the Plan to pay an additional amount for adding a tooth to an existing partial denture. You say that you were told the Plan would pay up to $2000 in dental benefits. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one every year.
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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of adding a tooth to an existing partial denture have not been met. Specifically, the record shows that you had exceeded the frequency limit for this service. Therefore, we decided that the Plan does not have to pay an additional amount for adding a tooth to an existing partial denture (D5650 x2).