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

We decided that the Plan does not have to pay for the office visit provided on April 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 office visit provided on April 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound therapy and x-rays provided from March 20, 2021, March 24, 2021 and March 26, 2021.

You asked the Plan to pay for ultrasound therapy (97035), thoracic spine x-ray (72070), and lumbosacral x-ray (72100). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the ultrasound and x-rays are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the ultrasound therapy and x-rays provided from March 20, 2021, March 24, 2021 and March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-rays (D0277), prophylaxis (D1110), and resin-based composite (D2394) provided from January 14, 2021, to April 9, 2021 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, bitewing x-rays, prophylaxis, and resin-based composite. You say that according to your summary of benefits, you can go to either an in-network or OON provider, and the Plan will cover up to $1,000 for services. You also say that there are no in-network providers in your area. The Plan denied your request. The Plan says the cost share was applied correctly per your plan benefits. The Plan also says that cost-sharing is a contractual obligation of the Plan and cannot be waived. 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, you are responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-rays (D0277), prophylaxis (D1110), and resin-based composite (D2394) provided from January 14, 2021, to April 9, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits received on June 5, 2020, and June 15, 2020.
You asked the Plan to waive the copayments for the visits. You say that the copayments should be waived. The Plan denied your request. The Plan says the copayment is the enrollee's responsibility.
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 $35 copayment for office visits. You have been asked to pay a $35 copayment for the visits. The visits fall within the office visits 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 office visits received on June 5, 2020, and June 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays and 2D oral/facial photographic images provided on May 1, 2020.
You asked the Plan to pay for the intraoral x-rays and 2D oral/facial photographic images. You say that you were told the services were denied for being out-of-network, but an exception would be made. You say that payment in full was required and you are requesting reimbursement. The Plan denied your request. The Plan says an intraoral x-ray is only allowed once per calendar year and 2D oral/facial photographic images is not a covered benefit.
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, an intraoral x-ray is only covered once every calendar year. The Plan paid for the intraoral x-ray provided on April 27, 2020, which exhausted your benefit. The 2D oral/facial photographic images are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays and 2D oral/facial photographic images provided on May 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on July 15, 2020. You asked the Plan to waive the copayment for the x-ray. You say that you had a routine physical and should not be charged for the x-ray. 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 $40 copayment for each Medicare-covered x-ray. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $40 copayment for the x-ray.
You have been asked to pay a $39.83 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the x-ray was done in addition to the routine physical exam. 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 x-ray provided on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visits provided on February 23, 2021 and March 2, 2021.

You asked the Plan to waive the copayment for the specialist office visits. You say that you should not be charged for a prothrombin test. 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 $35 copayment for each Medicare-covered specialist visit. For these dates of service, you have been asked to pay the allowed amounts of the claims because these amounts are less than the standard $35 copayment for the specialist office visits.

You have been asked to pay a $24.86 copayment for the specialist office visits on each date of service. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were charged for the specialist office visits and there were no charges for the prothrombin tests.

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 specialist office visits provided on February 23, 2021 and March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the inherited cardiomyopathy panel provided on January 18, 2021.

You asked the Plan to pay for the testing services. You say that the services were rendered in good faith. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for suspected or documented cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

We looked at the file and the rules. The records provided show that the enrollee has no personal history of cardiovascular disease. The testing services were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the inherited cardiomyopathy panel provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve these services. You say that you would like a new referral. The Plan denied your request. The Plan says the services are available from network providers.

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 a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that the enrollee has tried and failed conservative
therapies, simple analgesics/steroid injections. The Plan denied your request. The Plan says the enrollee has not
tried and failed the preferred drugs, Monovisc and Orthovisc. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the
requested drug, Durolane, is not medically necessary. Our physician reviewer found the Plan requires a trial of
drug Monovisc and Orthovisc before they will approve the requested drug. The reviewer found that the enrollee
has not tried and failed the required drugs. The reviewer found that there is no documentation provided
indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the
enrollee. Therefore, the reviewer found that the step therapy criteria has not been met and therefore the
requested drug is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Specifically, the file does not show that the
enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to preapprove
Durolane (J7318).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an injection (64450) provided on February 10, 2021.
You asked the Plan to pay for an injection. You say that this is supported in the records. The Plan denied your
request. The Plan says that this code cannot be reported for anesthesia for a surgical procedure.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan denied this service because it was billed with a code that should not be
used to report anesthesia for a surgical procedure. However, the records do not show that this was used to
report anesthesia for a surgical procedure. No documentation was provided to support that a surgical procedure
was also performed and billed. Therefore, we decided that the Plan has to pay for an injection (64450) provided
on February 10, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (28730) provided on January 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 28730 is "Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse". 

We asked our coder 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 use of code 28730 is not supported by the records provided. Our reviewer found that the operative report does not include
documentation of arthrodesis of tarsometatarsal, therefore, CPT 28730 cannot be confirmed. 

We looked at this coder'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 the services (28730) provided on January 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that the enrollee has tried non-drug and simple analgesic
therapy with no improvement. You also say that the requested drug is medically necessary. The Plan denied
your request. The Plan says the enrollee has not tried and failed the preferred drugs, Orthovisc and Monovisc. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Durolane. Our reviewer says that the
requested drug, Durolane, is not medically necessary. Our physician reviewer found the Plan requires a trial of
drug Monovisc and Orthovisc before they will approve the requested drug. The reviewer found that the enrollee
has not tried and failed the required drugs. The reviewer found that there is no documentation provided
indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the
enrollee. Therefore, the reviewer found that the step therapy requirements have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Specifically, the file does not show that the
enrollee has tried and failed the required drugs. Therefore, we decided that the Plan does not have to preapprove
Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the procedure codes billed 95955-26, 95885-26-59 x2 and
95909-26.

You asked the Plan to pay for the procedure codes billed 95955-26, 95885-26-59 x2 and 95909-26. You say
that you would like these claims reprocessed and approved for payment. The Plan denied your request. The
Plan says the services are not supported by the medical records 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.

In this case, the CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during
nonintracranial surgery (eg, carotid surgery). The CPT Code Manual definition of code 95885 is Needle
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction,
amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).
Finally, the CPT Code Manual definition of code 95909 is Nerve conduction studies; 5-6 studies.

We asked our coder 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 procedure codes billed 95955-26, 95885-26-59 x2 and
95909-26. Our reviewer says that the medical records do not support the services as billed. Our reviewer found
CPT 95909 is not supported by the documentation submitted. Pedicle screw stimulation is documented in the
technical report, which would not be reported with nerve conduction studies. Nerves are stimulated with
electrode patches placed on the skin over the nerve being tested. Therefore, CPT 95909 would not be
covered. CPT 95885 includes nerve conduction studies, as there is no documentation to support nerve
conduction studies were performed, this procedure cannot be confirmed. CPT 95955 should not be reported for
real time monitoring and would be included with intraoperative monitoring procedure.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the procedure codes billed 95955-26, 95885-26-59 x2 and 95909-26 have not
been met. Therefore, we decided that the Plan does not have to pay for the procedure codes billed 95955-26,
95885-26-59 x2 and 95909-26.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on January 26, 2020.
You asked the Plan to pay for the rotary wing air transport and rotary wing air mileage. You say that this transport was a medical emergency for the enrollee. The Plan denied your request. The Plan says this claim was received on April 12, 2021 which is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the rotary wing air transport and rotary wing air mileage was not filed until April 12, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air mileage (A0436) provided on January 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology visit provided on April 27, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the neurology visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 neurology visit provided on April 27, 2020 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from February 11, 2021, to February 27, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The file shows that the claims were not billed on the required 032x Type of Bill. 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 home health services rendered from February 11, 2021, to February 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (ECG) interpretation rendered on November 30, 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 93010 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of an ECG report and interpretation for at least 12 leads. 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 electrocardiogram (ECG) interpretation rendered on November 30, 2020.