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

We decided that the Plan does not have to pay for Magnetic Resonance Angiography (70544) provided March 23, 2021.

You asked the Plan to pay for the Magnetic Resonance Angiography. You say that the services were medically necessary. The Plan denied your request. The Plan says the service billed is not eligible for separate payment.

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 70544 has a Column One/Column Two relationship with code 70551 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 for Magnetic Resonance Angiography (70544) provided March 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided May 12, 2020.
You asked the Plan to pay for therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 CPT code 97110 is not supported in the medical record. Specifically, the documentation shows the services were provided in the home setting. There is a more appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on February 1, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on February 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 11, 2021.You asked the Plan to waive the copayment for the MRI. You say that you were told by a Plan representative that your copayment for the MRI would be $150 and you are disputing the extra $50 applied to your cost share.The Plan denied your request. The Plan says you received an MRI on the date of service at issue in this appeal. The Plan says that the correct copayment has 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 $200 copayment for diagnostic radiology other than CT scans. 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an MRI on January 11, 2021. You have been asked to pay a $200 copayment for the MRI as your total cost share. The MRI falls within the Outpatient diagnostic tests 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 MRI provided on January 11, 2021.Your complaint about being provided the incorrect information from the Plan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230) provided on January 19, 2021.
You asked the Plan to pay for intraoral x-rays. You say that your contract shows that you have coverage for the x-rays in question, and you should be reimbursed. The Plan denied your request. The Plan says these x-rays are not covered by your dental Plan. Intra-oral x-rays can be covered under the optional additional dental plan, which is offered for an additional monthly premium, but you were enrolled in the mandatory dental plan on the date in question.
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. Documentation shows that you were enrolled in the mandatory dental plan on January 19, 2021, which does not cover intraoral x-rays. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0220, D0230) provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for therapeutic continuous glucose monitor (CGM) supplies provided on
January 21, 2021.

You asked the Plan to pay for therapeutic CGM. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says that the denial of payment for these supplies is correct, because the
records submitted do not support the medical necessity of the items billed.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and
necessary for enrollees with diabetes who meet criteria referenced above.

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 therapeutic CGM. Our reviewer says that
these supplies meet the Medicare criteria for coverage. Our physician reviewer found the enrollee clearly has
type II diabetes mellitus, he is testing his glucose 5 times daily, he is using insulin via a continuous
subcutaneous insulin infusion (CSII) pump, and he is adjusting his regimen based on a sliding scale.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of therapeutic CGM have been met. Therefore, we decided that the Plan has to pay
for therapeutic continuous glucose monitor (CGM) supplies provided on January 21, 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 diagnostic or therapeutic agent injection (64493, 64494) provided September 2, 2020.

You asked the Plan to pay for diagnostic or therapeutic agent injection. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 64493 and 64494 is 2 You billed 2 units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of diagnostic or therapeutic agent injection have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic or therapeutic agent injection (64493, 64494) provided September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on February 26, 2021.You asked the Plan to waive the copayment for the x-ray. You say that you were told your x-ray was not covered since it was not done in the doctor's office. 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 $110 copayment for each covered x-ray in the outpatient department of a network hospital or facility. 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 $110 copayment for the x-ray at an in-network outpatient hospital.
You have been asked to pay a $101.22 copayment for the x-ray. The x-ray 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 the x-ray provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on September 24, 2020.
You asked the Plan to pay for the durable medical equipment. 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 must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. 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 the durable medical equipment provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital services (99232) provided on February 17, 2021.

You asked the Plan to pay for subsequent hospital services. You say that that you would like reconsideration because the payment for these services is not included in the payment for the services of another physician. The Plan denied your request. The Plan says the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital services have not been met. Specifically, CPT code 99232 was billed on the same date of service as another evaluation and management service (99291) rendered by a provider in the same group with the same specialty. There is no indication that these services were for unrelated problems. Therefore, we decided that the Plan does not have to pay for subsequent hospital services (99232) provided on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 19, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records did not clearly show what difference in treatment options would be considered based on the results of this genetic testing. Also, there isn't sufficient support made from current literature stating genetic testing results in measurable improvement in overall outcomes in patients compared to standard testing and clinical assessments and treatment. Therefore, this request for the hereditary cardio genetic screening panel will be considered not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation -new or established patient (D0150), intraoral -complete series of radiographic images (D0210), panoramic radiographic image (D0330), limited oral evaluation -problem focused (D0140), and prophylaxis -adult (D1110) provided February 1, 2021 and February 12, 2021.You asked the Plan to pay for the comprehensive oral exam, intraoral x-rays, panoramic x-rays, limited oral exam and cleaning. You say that the dental office said they accepted your dental plan.The Plan denied your request. The Plan says they have covered the limited oral exam as an emergency service,but you are responsible for the difference between the allowed amount and the total cost charged by the OON provider. The remaining services are not covered when provided OON.
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. The Plan covers the comprehensive oral exam, intraoral x-rays, panoramic x-rays,limited oral exam and cleaning when the services are provided by a network provider. We looked at the file and Medicare rules. In this case your received services from an out-of-network dentist. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam, intraoral x-rays, panoramic x-rays, limited oral exam and cleaning have not been met.Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation -new or established patient (D0150), intraoral -complete series of radiographic images (D0210), panoramic radiographic image (D0330), limited oral evaluation -problem focused (D0140), and prophylaxis -adult (D1110) provided February 1, 2021 and February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on January 4, 2021.
You asked the Plan to waive the copayment for the colonoscopy with biopsy. 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 a colonoscopy with biopsy at an ambulatory surgical center on the date of service at issue in this appeal. The Plan says that the correct copayment has 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 $200 copayment per visit for Medicare-covered outpatient surgery or procedure at an ambulatory surgical center (ASC). We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a colonoscopy with biopsy on January 4, 2021 at an ambulatory surgical center. You have been asked to pay a $200 copayment for the colonoscopy with biopsy. The colonoscopy with biopsy falls within the Outpatient surgery 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 colonoscopy with biopsy provided on January 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for an established patient (99348) provided on May 5, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the service was rendered prior to the enrollee's admission into hospice care. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. The hospice election is based on the date it is elected and is not time specific. Therefore, we decided that the Plan does not have to pay for the home visit for an established patient (99348) provided on May 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xyrem.

You asked the Plan to pre-approve Xyrem. You say that Xyrem is helping the enrollee. The Plan denied your
request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xyrem.

Benefits for Xyrem may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (43425) provided on October 7, 2020.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 43425 is "Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)".We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 43425 is not supported by the records provided. Our coding reviewer found that the medical records 
provided do not include sufficient documentation to verify that an "Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)" was performed on October 7, 2020, therefore this service cannot be verified.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 (43425) provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services provided to the enrollee from February 4, 2020, through June 4, 2020.

You asked the Plan to pay for the office services. You say that you put the claim through No-Fault and it was not covered. You state you spoke with Medicare and were told it should be put through by your health plan. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the office services until the primary insurer has denied the claim for these services. It has been determined that the records cannot be accepted as proof that the claims are not related to the open No-Fault case. The provider needs to prove that the service is unrelated and there is no clear indication as to the cause of the enrollee's neck and back pain. The contract states that No-Fault insurance (including automobile insurance) pays first for related services. As it has not been confirmed that this service is unrelated to the open No-Fault case, the Notice of Denial of Payment for dates of service February 4, 2020, and June 4, 2020, is upheld. Therefore, we decided that the Plan does not have to pay for the office services provided to the enrollee from February 4, 2020, through June 4, 2020.