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

We decided that the Plan does not have to pay for an office visit (99213) provided on July 16, 2020.

You asked the Plan to pay for an office visit. You say that this was billed correctly. The Plan denied your request. The Plan says this should be billed with a bilateral diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

We find that these services cannot be paid as billed. Specifically, these services were billed with ICD-10-CM codes G56.21, lesion of ulnar nerve, right upper limb, and G56.22, lesion of ulnar nerve, left upper limb. There is a more appropriate bilateral code for this diagnosis, G56.23. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fluid Flow of Fluid GF.
You asked the Plan to pre-approve Fluid Flow or Fluid GF. You say that you would like reconsideration because you have painful, swollen knees that keep you up and restrict your mobility. The Plan denied your request. The Plan says this procedure is considered experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Fluid Flow or Fluid GF. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational formulation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fluid Flow or Fluid GF have not been met. Therefore, we decided that the Plan does not have to pre-approve the Fluid Flow of Fluid GF.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 8, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 prosthetic foot (L5981, L5968).
You asked the Plan to pre-approve the K3 prosthetic foot. You say that the K3 foot is medically necessary. The Plan denied your request. The Plan says the record does not support that the enrollee needs a K3 level foot.
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. 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 K3 prosthetic foot. Our reviewer says that the K3 prosthetic foot is not medically necessary. Our physician reviewer found the record shows the member uses a cane indoors and outdoors, which is inconsistent with K3 functional level. 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 K3 prosthetic foot have not been met. Therefore, we decided that the Plan does not have to pre-approve a K3 prosthetic foot (L5981, L5968).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on March 25, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you already paid the copayment. The
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the
correct 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 $210
copayment for CT scans.
You have been asked to pay a $210 copayment for a CT scan. A CT scan falls 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
for a CT scan provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on December 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that this is supported by the medical records. The Plan denied your request. The Plan says this 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 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 an office visit (99214) provided on December 22, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 11, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that the appointment was due to a skin reaction after receiving the first dose of the vaccination. You say that you would appreciate payment of the invoice for $30 and the reimbursement of the prescription. 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 $30 copayment for each visit in a contracted urgent care center or walk-in clinic. You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the "Urgently Needed 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 the urgent care visit provided on January 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 28, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (CPT code 90832) provided to the enrollee on August 26, 2020, by a non-participating provider.
You asked the Plan to pay for the psychotherapy services. You say that you rendered treatment to the enrollee in good faith that the service will get reimbursed. The Plan denied your request. The Plan says the provider did not make attempts to verify the enrollee's correct insurance, eligibility, or authorization requirements prior to rendering non-emergent services. The Plan states there is no evidence of plan directed care and the enrollee was not receiving skilled services or inpatient services during this time.
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 psychotherapy services (CPT code 90832) provided to the enrollee on August 26, 2020, by a non-participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 12, 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 66984 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 66984 is extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. We find that CPT code 66984 is not supported in the medical record. Specifically, there is no documentation of cataract removal, only a transfer agreement for post-operative care. 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 surgical services rendered on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit for vision services and the diagnostic test provided on February 11, 2021.
You asked the Plan to waive the copayments for the office visit for vision services and the diagnostic test. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an office visit for vision services and diagnostic tests on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 copayment for each office visit to other providers and a $10 copayment for diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an office visit for vision services and diagnostic tests on February 11, 2021. You have been asked to pay a $45 copayment for the office visit for vision services. The office visit for vision services falls within the Vision care benefit category. You have also been asked to pay a $10 copayment for the diagnostic test. The diagnostic test falls within the Outpatient diagnostic tests benefits category. This means that you have been asked to pay the correct amounts 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 the office visit for vision services and the diagnostic test provided on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for each x-ray and specialist visit provided on November 9, 2020.
You asked the Plan to waive the copayments for each x-ray and specialist visit. 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 4 x-ray services and a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $14 copayment for each Medicare-covered standard x-ray service and a $40 copayment for services obtained from a specialist in a specialist's office. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received 4 x-rays and a specialist visit on November 9, 2020. You have been asked to pay a $14 copayment for each x-ray. The x-rays fall within the Outpatient diagnostic tests benefit category. You have also been asked to pay a $40 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 each x-ray and specialist visit provided on November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatological services (17000, 17110, 99203) provided on February 18, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the dermatological services. You say that you did not believe prior authorization was still needed for services received from an OON provider. The Plan denied your request. The Plan says prior authorization was not obtained before these services were 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 dermatological services (17000, 17110, 99203) provided on February 18, 2021 by an out of network (OON) provider.
Your complaint about potentially receiving incorrect information from the Plan regarding prior authorization 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) on October 4, 2020.
You asked the Plan to pay for the electronic shock unit. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support the billed service
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The submitted itemized invoice contains a discrepancy with the billing provider's shipping address. The billing provider is not located at the shipping address documented in the medical record therefore, the servicing provider cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) on October 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on September 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy 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 payable.
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 psychotherapy services provided on September 16, 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 the podiatry services provided on January 25, 2021 by an out of network provider.
You asked the Plan to pay for the podiatry services. You say that the enrollee presented with foot pain and the medical records support the services. The Plan denied your request. The Plan says you did not request prior authorization.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 the podiatry services provided on January 25, 2021 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on August 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 psychotherapy services (90837) provided on August 27, 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 the out of area office visit services provided on December 11, 2020.
You asked the Plan to pay for the out of area office visit services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out of area care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows that the out of area office visit services provided on December 11, 2020 were neither emergent nor urgent and prior authorization was not obtained. Based on this information, we decided that Medicare rules for coverage of the out of area office visit services have not been met. Therefore, we decided that the Plan does not have to pay for the out of area office visit services provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that electrical nerve stimulation 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic thoracic pain syndrome, myofascial pain, thoracic spondylosis, and degenerative scoliosis. She has had trials of Ultracet and Lidocaine patches and has had trigger point injections. The records do not support that the criteria for the requested PENS device are met; therefore, the services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS).