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

We decided that the Plan does not have to pay forpayment for telehealth distant site services (G2025) provided on May 15, 2020.You asked the Plan to pay forthe payment for telehealth distant site services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim was not billed per Medicare guidelines.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 G2025 is not supported in the record. Specifically, the telehealth distant site services were not billed with the required CPT codes and modifier. Based on this information, we decided that Medicare rules for coverage of the payment for telehealth distant site services have not been met.Therefore, we decided that thePlan does not have to pay forpayment for telehealth distant site services (G2025) provided on May 15, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe filling (D2392) for tooth # 12 provided on July 16, 2020.You asked the Plan to pay forthe dental service. You say that you did not think that you were getting work done on the same tooth that you had fixed 2 years prior. You say you wereadvised that the service would only cost you $37. You say that you were surprised by the large bill that you received in the mail.The Plan denied your request. The Plan says fillings are limited to 1 per tooth, every 36 months. The Plan also says that the frequency limit has been exceeded.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 frequency limit of 1 filling per tooth every 36 months has been exceeded. The record shows that you received a filling on tooth # 12 that you received on August 13, 2018.Therefore, we decided that the Plan does not have to pay forthe filling (D2392) for tooth # 12 provided on July 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the chest (71552)
and an MRI of the breast (77049).
You asked the Plan to pre-approve these services. You say that the magnetic resonance imaging services
requested are medically necessary for the enrollee. The Plan denied your request. The Plan says that the
magnetic resonance imaging services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
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 magnetic resonance imaging services requested are not medically necessary for the enrollee. Our physician
reviewer found that the submitted documentation notes the enrollee reported left axillary pain and bilateral
palpable lumps. The enrollee had a breast ultrasound and a computed tomography study of the abdomen and
pelvis. The documentation does not include a detailed history and physical, differential diagnosis, or rationale
for the requested magnetic resonance imaging studies. Without the support of the documentation, medical
necessity cannot be determined.
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 magnetic resonance imaging (MRI) of the chest (71552) and an MRI of the breast (77049).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mastectomy (19302) provided on June 3, 2020.You asked the Plan to pay forthe mastectomy. You say that you would like reconsideration because this service was medically necessary.The Plan denied your request. The Plan says the assistant surgeon must bill the same CPT code as the primary surgeon.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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the mastectomy. Our reviewer says that CPT code 19302 does not meet criteria for billing or reimbursement consideration. Our reviewer found if an assistant surgeon assists a primary surgeon and is present for the entire operation, or a substantial portion of the operation, then the assisting physician reports the same surgical procedure as the operating surgeon.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 mastectomy have not been met.Therefore, we decided that the Plan does not have to pay forthe mastectomy (19302) provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for payment for a telehealth distant site service (G2025) provided.

You asked the Plan to pay for payment for a telehealth distant site service. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this code has not been reported per Medicare guidelines.

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 G2025 is not supported in the record. Specifically, this service has not been reported with the appropriate CPT codes and modifier. Based on this information, we decided that Medicare rules for coverage of payment for a telehealth distant site service have not been met.Therefore, we decided that the Plan does not have to pay for payment for a telehealth distant site service (G2025) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 15, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were informed you had to see
a psychiatrist if you wanted to be treated. You say that you should have been told what the copayment would
be prior to the appointment. 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 $35
copayment for each in-network specialist visit for Medicare-covered services.
You have been asked to pay a $35 copayment for the office visit. The office visit 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 waive the copayment for the office visit provided on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on June 23, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests 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, a cardiovascular risk assessment panel, 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 forthe laboratory services rendered on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Beasy transfer system (E1399).
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your contractual policy or by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose, and not be mainly for patient comfort or caregiver convenience. The item at issue in this appeal has added features beyond what is included in a standard transfer board. These features are considered to be primarily for patient comfort and caregiver convenience. As such, this particular type of transfer board does not meet Medicare criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve a Beasy transfer system (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care (99231) provided July 9, 2020.You asked the Plan to pay forsubsequent hospital care. You say that another claim processed and paid on 8/25/2020. This is the reason for the modifier 25 billed on the 99214. Please review and process for payment.The Plan denied your request. The Plan says the procedure code is inconsistentwith the modifier used. Missing required modifier.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 99231 is subsequent hospital care.We find that CPT code 99231 is not supported in the medical record. Specifically, the modifier Q0 or Q1 must be appended to the clinical service for participants in a clinical research program within the previous or subsequent 30 days. This information is based on the CMS IOM Medicare Claims Processing Manual, Chapter 32 (Billing Requirements for Special Services), Section 68.4 and 69.2, 69.6, 69.8 and 69.9. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been met.Therefore, we decided that the Plan does not have to pay forsubsequent hospital care (99231) provided July 9, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay provided by a participating provider on July 14, 2020, to July 15, 2020.You asked the Planto waive the copayment for an inpatient stay. You say that you should not have to pay for this because the doctor couldn't take a good EKG. The Plan denied your request. The Plan says the correct copayment has been applied.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 $300 copayment for inpatient hospital care. You have been asked topay a $300 copayment for an inpatient stay. An inpatient stay falls 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 contractualobligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient stay provided by a participating provider on July 14, 2020, to July 15, 2020. We note your complaint about the EKG not being usable. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laparoscopy provided from September 24,
2020, to September 25, 2020.
You asked the Plan to waive the copayment for a laparoscopy. You say that you disagree with the charges
because you were admitted and should only owe a $275 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 $350
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
The medical records show that you received a laparoscopy on September 24, 2020, to September 25, 2020,
from an outpatient hospital facility. Therefore, you are responsible to pay the $350 copayment.
You have been asked to pay a $350 copayment for a laparoscopy. A laparoscopy falls 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 a laparoscopy provided from September 24,
2020, to September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation and surgical extraction provided on August 24, 2020, and September 23, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and surgical extraction. You say that these services should be covered because a Plan representative told you they would be. The Plan denied your request. The Plan says the problem focused limited oral evaluation exceeds the frequency limitations under your plan. The Plan also says that you are responsible for 100% of the cost for surgical extractions.
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, emergency oral evaluation problem focused exams are limited to once every 12 months. The record shows that you received a limited oral evaluation on March 25, 2020, and your emergency oral evaluation problem focused exams benefit has been exhausted. The contract also clearly states that you are responsible for 100% of the cost for Class 3 Major Services, which includes surgical extractions. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation and surgical extraction provided on August 24, 2020, and September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray interpretation provided on August 18, 2019.You asked the Plan to pay forthe chest x-ray interpretation. You say that you did not have this service done.The Plan denied your request. The Plan says the claim was from an emergency room visit and was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the chest x-ray interpretation was not filed until August 28, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe chest x-ray interpretation provided on August 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 9, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat 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. ThePlandid not pre-approve the physician's services. 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 physician's services provided on July 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co payments for the myocardial perfusion imaging and the echo cardiography services received.

You asked the Plan to waive the co payments for the myocardial perfusion imaging and the echo cardiography services. You say that you disagree with the amount owed.The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 co payment for each outpatient diagnostic test. 

You have been asked to pay a $110 co payment for the myocardial perfusion imaging and a $110 co payment for the echo cardiography services. The myocardial perfusion imaging and the echo cardiography services 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 co payments for the myocardial perfusion imaging and the echo cardiography services received.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomographic angiography (75635).You asked the Plan to pre-approvea computed tomographic angiography. You say that this is medically necessary.The Plan denied your request. The Plan says the medical records do not show that this is indicated for the enrollee at this time.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 computed tomographic angiography. Our reviewer says that the documentation does not support the medical necessity of the study in question. Our physician reviewer found although the submitted medical records suggest rest pain and tissue loss, the language is very nonspecific and may be template/computer generated.  The physical examination describes palpable pedal pulses and there is a reference in the progress note of a right toe index of 1.31 (suggestive of satisfactory perfusion). The most recent progress note concludes that the patient's peripheral artery disease is well controlled and that he has no complaints.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 computed tomographic angiography have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomographic angiography (75635)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided by a participating provider on August 12, 2020.
You asked the Plan to waive the copayment for podiatry services. You say that you were told that this would have no charge. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for podiatry services. You have been asked to pay a $40 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided by a participating provider on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the influenza vaccine (G0008, 90662) provided on February 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON influenza vaccine. You say that you were not informed this provided was no in-network. The Plan denied your request. The Plan says this service 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 has network providers available who can provide 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 influenza vaccine (G0008, 90662) provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Victory 4-wheel scooter.You asked the Plan to pre-approvethe scooter. You say that this is medically necessary.The Plan denied your request. The Plan says this is needed for use outside of the home.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 thescooter. Our reviewer says that the requested scooter is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal a personal mobility deficit that impairs participation in MRADLs in thehome. Your mobility deficit is currently helped by a walker or cane. The documentation reveals no evidence that the scooter will significantly improve MRADLs in the home. This is being requested for outdoor use.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 scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvea Victory 4-wheel scooter