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

We decided that the Plan does not have to pay for the laboratory services coded 81231, 81240, 81241, 81328, 81230 and 81291 provided on November 19, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the laboratory services are not supported in the medical record. Specifically, the documentation does not support that the services rendered were ordered/approved by the ordering provider. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81231, 81240, 81241, 81328, 81230 and 81291 provided on November 19, 2020.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the spine surgery. We decided that the Plan does not have to
waive the cost for the spine surgery.

You asked the Plan to waive the cost for the spine surgery. You say that you should not be responsible for this
amount. The Plan says that the coinsurance applied correctly.

We decided that the Plan has to reduce the cost for the spine surgery.

The Plan says that you must pay 20% coinsurance for the spine surgery. The records show the spine surgery
was an inpatient procedure, which would apply the inpatient copayment. The Evidence of Coverage clearly
states that you pay a $298 copayment per day, for days 1 to 7 for in-network inpatient hospital care. Therefore,
we decided that the Plan has to reduce the cost for the spine surgery from $785.86 to $298.

We also decided that the Plan does not have to waive the cost for the spine surgery.

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 $298
copayment per day, for days 1 to 7 for in-network inpatient hospital care. The spine surgery was an inpatient
procedure. Therefore, we decided that the Plan does not have to waive the cost for the spine surgery.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87798, 87486, 87541, 87581, 87640, 87496, and 87498 provided on April 17, 2020.

You asked the Plan to pay for the laboratory 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. 

We find that the laboratory services are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87798, 87486, 87541, 87581, 87640, 87496, and 87498 provided on April 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on March 13, 2021.

You asked the Plan to pay for an x-ray. You say that this is supported in the records. The Plan denied your request. The Plan says this was previously billed and paid.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that an additional unit of CPT code 71045 is not supported in the medical record. The medical record only supports 1 unit of CPT code 71045, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for nervous system services (CPT 64999) provided to the enrollee on June 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 Current Procedural Terminology (CPT) code 64999-59, RT (1 unit) remains 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 64999 is "Unlisted procedure, nervous system." 

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 services at issue in this case were not supported by the medical records. Our coding reviewer found the procedure report does not include documentation to confirm the unlisted procedure performed. When submitting an unlisted code supporting information outlining the decision-making process and medical rationale for performing the operation to confirm Medicare coverage criteria have been met. In this case, documentation submitted does not clearly support to use of CPT 64999, and therefore, would not be covered.

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 nervous system services (CPT 64999) provided to the enrollee on June 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 23,
2020.

You asked the Plan to waive the copayment for the endoscopy. You say that you were never told there was
going to be a copayment and you can't pay this amount. 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 $295
copayment for Medicare-covered surgery or other services provided to you at an in-network ambulatory
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $295 copayment for the endoscopy. The endoscopy falls within the "Outpatient
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers" 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 endoscopy provided on
November 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a central venous catheter (36573-26) provided on November 12, 2020.
You asked the Plan to pay for the insertion of a central venous catheter. You say that this was billed correctly. The Plan denied your request. The Plan says this cannot be billed with modifier 26.
The Plan must follow Medicare rules. Medicare rules say that codes with a Professional Component (PC)/Technical Component (TC) Indicator of 0 in the Physician Fee Schedule cannot be billed with Modifiers 26 or TC.
We looked at the file and Medicare rules. Code 36573 has a PC/TC indicator of 0 in the Physician Fee Schedule, but was billed with Modifier 26. Based on this information, we decided that Medicare rules for coverage of the insertion of a central venous catheter have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of a central venous catheter (36573-26) provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services (99222, 99232) provided from December 23, 2019, to December 26, 2019.

You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that you were told that you would not be liable for any expenses for these services. The Plan denied your request. The Plan says this cost-sharing was applied correctly, and you are responsible for your 20% coinsurance for inpatient hospital services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for inpatient hospital care. 

The providers billed the Plan a total of $801 during the four-day inpatient hospital stay. However, the Plan's allowed amount for these services comes to $383.04. Your 20% coinsurance applies to this amount. You have been asked to pay $76.61 ($383.04 x 20% coinsurance = $76.61). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the inpatient hospital services (99222, 99232) provided from December 23, 2019, to December 26, 2019.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the ultrasound. We decided that the Plan does not have to waive the copayment for the ultrasound.

You asked the Plan to waive the copayment for the ultrasound. You say that you never thought you would have to pay for any out of pocket expenses for ultrasounds with insurance. You say that you don't have the money to pay. The Plan says that the claim reprocessed to apply a $30 copayment.

We decided that the Plan has to reduce the copayment for the ultrasound.

The Plan says you must pay a $30 copayment for the ultrasound based on the x-ray benefit. An ultrasound is not considered an x-ray. The Evidence of Coverage states you pay a $10 copayment for other outpatient diagnostic tests. Therefore, we decided the Plan must reduce the copayment for the ultrasound from $30 to $10.

We also decided that the Plan does not have to waive the copayment for the ultrasound.

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 $10 copayment for other outpatient diagnostic tests. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), three pontics (D6245 x3), and four retainer crowns (D6740 x4) provided on February 16, 2021, and March 4, 2021.
You asked the Plan to pay for the core buildup, pontics, and retainer crowns. You say that you received this bridge because your forty-year-old bridge had failed. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950), three pontics (D6245 x3), and four retainer crowns (D6740 x4) provided on February 16, 2021, and March 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on February 6, 2020, to March 9, 2021, by a practitioner who had opted out of Medicare.

You asked the Plan to pay for psychotherapy services. You say that you were unaware that the provider opted out of Medicare. You also say that the provider is the only doctor who has been able to help you with your conditions. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue had opted out of Medicare.

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 involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who had opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on February 6, 2020, to March 9, 2021, by a practitioner who had opted out of Medicare.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spine injection provided on June 15, 2020 and September 14, 2020.

You asked the Plan to waive the copayment for the spine injections. You say that you have been going there for years and this cost has not happened before. You say that this is for an injection done by the doctor and you paid a $20 copayment. The Plan denied your request. The Plan says the copayments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center.

You have been asked to pay a $150 copayment for each spine injection. The spine injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 spine injection provided on June 15, 2020 and September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on November 24, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prostate artery embolization.

You asked the Plan to pre-approve a prostate artery embolization. You say that this is medically necessary over the alternative procedures. The Plan denied your request. The Plan says prostate artery embolization is not supported by current data and trial designs.

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 a prostate artery embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization is considered an experimental technique to treat symptomatic benign prostatic hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy. The most recent guidelines do not recommend this procedure outside of a clinical trial setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve a prostate artery embolization.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing (88342, 86305) provided on January 14, 2021, by an out of network (OON) provider.

You asked the Plan to pay for laboratory testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider at issue is not contracted with the Plan for medical services, there was no authorization on file and 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 laboratory testing (88342, 86305) provided on January 14, 2021, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections.
You asked the Plan to pre-approve facet injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are 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 facet injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the enrollee has radiculopathy and there is no documentation provided indicating that the pain has been present for a minimum of 3 months with documented failure to respond to noninvasive conservative care management as tolerated. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) (77021) provided on October 15, 2020.
You asked the Plan to pay for an MRI. You say that you should be fully reimbursed for this service. The Plan denied your request. The Plan says this is 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 77021
has a bundled relationship with code 77022 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 a magnetic resonance imaging (MRI) (77021) provided on October 15,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 4, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you were under the impression that this service would be paid in full. The Plan denied your request. The Plan says this service is not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 4, 2021.