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

We decided that the Plan does not have to pay for the medical services provided on September 9, 2020, by an OON provider.
You asked the Plan to pay for an eye exam. You say that the provided services were medically necessary. The Plan denied your request. The Plan says rules for payment to an out of network provider have 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 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 medical services provided on September 9, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe wound care supplies provided on August 25, 2020.You asked the Plan to waive the coinsurance forthe wound care supplies. You say that the enrollee was not aware there would be a copay.The Plan denied your request. The Plan says the enrollee was charged this copayment 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 enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Durable Medical Equipment and related supplies. The enrollee has been asked to pay 20% coinsurance for the wound care supplies. The wound care supplies fall within the Durable Medical Equipment and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe wound care supplies provided on August 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second endoscopic catheterization interpretation provided on August 8, 2020.
You asked the Plan to pay for a second endoscopic catheterization interpretation (74328). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the submitted documentation supports one unit which was previously approved and paid.
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 74328 is endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation. We find that CPT code 74328 is not supported in the medical record for two units. Specifically, there is no documentation supporting additional services. Based on this information, we decided that Medicare rules for coverage of a second endoscopic catheterization interpretation (74328) have not been met. Therefore, we decided that the Plan does not have to pay for a second endoscopic catheterization interpretation provided on August 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment provided from September 21,
2020, to October 21, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for durable medical equipment. 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 a participating
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
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 durable medical equipment provided from
September 21, 2020, to October 21, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on August 25, 2020, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for diagnostic radiology 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. 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 diagnostic radiology services provided on August 
25, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for TENS lead wires A4557 provided to the enrollee on
September 29, 2020.
You asked the Plan to pay for the TENS lead wires. You say that a set of replacement leads is not inclusive to
the initial set of wires received, so the claim should be paid. The Plan denied your request. The Plan says the
code for A4557 is for replacement wires, and it has not been twelve months since the TENS device, E0730(a
Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation)
was received so it is denied.
The Plan must follow Medicare rules. Medicare rules say that 'Replacement of lead wires more often than
every 12 months would rarely be reasonable and necessary'. Since a TENS unit has been purchased in the
previous 12 months, the lead wires have been denied. Records supporting the medical necessity of the
additional lead wires were not submitted.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the TENS lead wires have not been met. Therefore, we decided that the Plan does not have to pay
for TENS lead wires A4557 provided to the enrollee on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis services coded 20611 provided on August 7, 2020.

You asked the Plan to pay for the arthrocentesis services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.

We find that CPT code 20611 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of images to support the code billed. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis services have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis services coded 20611 provided on August 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance forinpatient hospital services provided from October 4, 2020, to October 7, 2020.You asked the Plan to adjust the coinsurance for inpatient hospital services. You say that the Plan should have covered more because the coinsurance is a lot of money for 3 days of service. The Plan denied your request. The Plan says you were charged this coinsurance 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 10% coinsurance of the total cost per admission for Inpatient Hospital Care. You have been asked to pay 10% coinsurance of the total cost per admission for inpatient hospital services. Inpatient hospital services 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 adjust the coinsurance for inpatient hospital services provided from October 4, 2020, to October 7, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinfusion therapy drugs to be provided at the in-network benefit level by an out-of-network provider.You asked the Plan to pre-approveinfusion drugs. You say that the denial of authorization for coverage at the in-network benefit level is correct, because this provider is out-of-network with the Plan and these drugs can be provided by an in-network provider.The Plan denied your request. The Plan says the denial of authorization at the in-network benefit level is correct, because this provider is out-of-network with the Plan and these drugs can be provided by an in-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you may choose to receive care from an out-of-network provider that is eligible to provide services under Original Medicare. 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 30% coinsurancefor out-of-network Part B drugs.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 at the in-network benefit level. You may choose to receive services from this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approveinfusion therapy drugs to be provided at the in-network benefit level by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, prophylaxis, and core buildup, including any pins when required provided on September 14, 2020.You asked the Plan to pay forthe periodic oral evaluation, bitewings, prophylaxis, and core buildup. You say that you were never told that this provider did not accept Medicare.The Plan denied your request. The Plan says the treating provider opted out of Medicare effective September 15, 2016, to September 15, 2022. The Plan also says that services performed by a privately contracted provider are not covered.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involvingemergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, prophylaxis, and core buildup, including any pins when required provided on September 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroffice outpatient visit (99204) provided on July 2, 2020.You asked the Plan to waive the copayment foroffice outpatient visit. You say that the service should be covered.The Plan denied your request. The Plan says the cost share was 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 $45 specialist copayment for physician/practitioner services, including doctor's office visits. You have been asked to pay a $45 specialist copayment for office outpatient visit. This service falls within the physician/practitioner services, including doctor's 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 waivethe copayment foroffice outpatient visit (99204) provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral photographic images (D0350) and the unspecified preventive service  (D1999) provided on October 6, 2020.You asked the Plan to pay forthe dental services. You say that you were not aware that the services were not covered. You also say that you did not receive any literature from the plan showing you what was covered and what was not covered.The Plan denied your request. The Plan says 2D oral photographic images are not listed as a covered service. The Plan also says that unspecified preventive service is not listed as a covered service.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. The record shows that there is no member liability for the unspecified preventive service as the provider has written-off this charge.Therefore, we decided that the Plan does not have to pay forthe 2D oral photographic images (D0350) and the unspecified preventive service  (D1999) provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99233) provided on January 10, 2020. You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the precertification entity was not contacted for precertification. 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 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 subsequent hospital care. Our reviewers says that CPT code 99233 meets criteria for billing and reimbursement consideration. Our physician reviewer found the record supports the service billed. 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 subsequent hospital care have been met. Therefore, we decided that the Plan has to pay for subsequent hospital care (99233) provided on January 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fornon-obstetrical transvaginal ultrasound (76830) non-obstetrical transabdominal ultrasound (76856) provided September 14, 2020.You asked the Plan to waive the copayment forthe diagnostic services. You say that you believe you are being charged a double copay for your complete pelvic ultrasound. You believe the 2 codes 76856 and 76830 should be combined in one charge.The Plan denied your request. The Plan says the claim was processed and the correct copayment 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 $110 copayment for each radiological diagnostic service, not including x-rays. You have been asked to pay $216.19 ($110 + $106.19) for the diagnostic services. The provider billed codes 76830 and 76856. The Medicare allowable for 76856 is $106.19. Since the allowable is less than the copayment, you are responsible for the allowable. The diagnostic services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 fornon-obstetrical transvaginal ultrasound (76830) non-obstetrical transabdominal ultrasound (76856) provided September 14, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) and urine analysis (82750, 81003) 
provided on August 4, 2020. 
 
You asked the Plan to pay for drug testing and urine analysis. You say that these services are supported in the 
medical records. The Plan denied your request. The Plan says these services were not billed correctly. 
 
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 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. The definition of code 82570 is creatinine; other 
source; and the definition of 81003 is urinalysis, by dip stick or tablet reagent for bilirubin, glucose, 
hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these 
constituents; automated, without microscopy. 
 
We find that CPT codes G0483, 82570, and 81003 are not supported in the medical record. Specifically, the 
documentation does not show that 22 or more drug classes were tested. Without this information, G0483 
cannot be verified. Codes 82750 and 81003 cannot be billed separately from the primary drug testing procedure 
and are included in the primary code. Based on this information, we decided that Medicare rules for coverage 
of drug testing and urine analysis have not been met. Therefore, we decided that the Plan does not have to pay 
for drug testing (G0483) and urine analysis (82750, 81003) provided on August 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services coded 74019 provided on September 18, 2020.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.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, we have confirmed that code 74019 for the x-ray services has a bundled relationship with code 74022 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe x-ray services coded 74019 provided on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional routine transportation services. You say that you need additional 
routine transportation trips because of your medical condition. The Plan denied your request. The Plan says 
they do not cover anything after the 36 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.