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

We decided that the Plan does not have to waive the copayment for the office visit provided on January 2, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you had to go to the hospital. You say that you are disputing the doctor bills. The Plan denied your request. The Plan says the claim reprocessed to only apply the $35 copayment.
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 specialist visit. 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 January 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on December 10, 2019.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that the procedure should have been completed the first time and disagree with the second 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $250 copayment for a cystourethroscopy. A cystourethroscopy 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 cystourethroscopy provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99201) provided on November 21, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit (99201) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on October 1, 2019.
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you thought that you would only owe a $50 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 $150 copayment for surgery services provided in an outpatient hospital facility. You received a cystourethroscopy at an outpatient hospital facility on October 1, 2019. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a cystourethroscopy. A cystourethroscopy 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 a cystourethroscopy provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a PET scan. You say that you have seen this provider before and would like to use this provider again. The Plan denied your request. The Plan says there are 15 cardiologists in-network that can provide the requested services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a PET scan to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 84480. We decided that the Plan does not have to pay for CPT
84479.
You asked the Plan to pay for the services. The Plan says that the services are not payable.
We decided that the Plan has to pay for CPT 84480.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The plan says that "CPT 84480 is a column II code to the column I code 84480
and these should not be billed together". This code was only billed once for the date of service in question, and
is not a column II code for any other code billed on the same date. The plan has not provided documentation to
substantiate its denial. Therefore, we decided that the Plan has to pay for CPT 84480.
We also decided that the Plan does not have to pay for CPT 84479.
Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and
the column one code is eligible for payment. Procedure code 84479 is part of an edit pair with procedure code
84439. Procedure code 84439 is a column one code, and procedure code 84479 is a column two code.
Procedure code 84439 has been paid for this date of services, which means that procedure code 84479 is not
eligible for payment. Therefore, we decided that the Plan does not have to pay for CPT 84479.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the uvula excision provided on October 28,
2019.
You asked the Plan to waive the copayment for the uvula excision. You say that you were covered with the
100% discount for the surgery. 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 surgery services at an in-network outpatient hospital.
You have been asked to pay a $295 copayment for the uvula excision. The uvula excision 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 the uvula excision
provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out of network (OON) provider on January 13, 2020. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 chiropractic manipulative treatment (98941) rendered by the out of network (OON) provider on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must have an approval from the plan before getting medical services or items from a specialist, an out-of-network provider, or certain other providers.
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 did not pre-approve the services 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 physician's services provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code 64999 provided on September 23, 2019.
You asked the Plan to pay for CPT code 64999. You say that the medical records support the billing of CPT
code 64999. The Plan denied your request. The Plan says that the medical records do not support the billing of
CPT code 64999.
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 64999 is supported in the medical record. Specifically, the medical records support that
an iPACK with ultrasound guidance was performed on September 23, 2019. The service was billed with CPT
code 64999 correctly, as there is no other CPT code available that accurately describes the procedure
performed. The American Hospital Association (AHA) and the Centers for Medicare & Medicaid Services
(CMS) have joined together in establishing the AHA clearinghouse to handle coding questions on established
HCPCS usage. Per AHA Coding Clinic for HCPCS - Volume 19, Number 4, code 64999 is the correct code for
the services performed. Therefore, we decided that the Plan has to pay for CPT code 64999 provided on
September 23, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019 by a non-network provider.
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 the services were rendered by a non-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 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 medical services provided on October 23, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 99406 and HCPCS G0480) provided to the enrollee on December 17, 2019.
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 the denied codes remain 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 the denied codes is: CPT 99406: Smoking and tobacco use cessation counseling visit HCPCS G0480: Drug test(s), definitive, utilizing (1) drug identification methods 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 services at issue in this case were not coded correctly. Our physician reviewer found the documentation submitted was reviewed, and does not support a counseling visit greater than 3 minutes up to 10 minutes. Documentation submitted was reviewed, and tests performed does not support HCPCS code G0480 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 lab services (CPT 99406 and HCPCS G0480) provided to the enrollee on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orcam device.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says this device is not a covered Medicare or Medicaid approved device.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 the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found this device is not a covered benefit.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approve an Orcam device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on December 16, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met.The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a physical examination of the ankles and feet. There is no documentation that the enrollee has weakness or deformity of the feet and ankles requiring stabilization for medical reasons.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on July 20, 2019 to December 10, 2019 by a non-Medicare provider.
You asked the Plan to pay for the services provided. You say that the chiropractor you found is working well for you, and is close to your area. The Plan denied your request.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive your care from a provider who is eligible to provide services under Original Medicare. The requested provider in this case is not eligible to provide services under Original Medicare. The Plan did not pre-approve the services 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 chiropractic services provided on July 20, 2019 to December 10, 2019 by a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Zoll Vest (K0606) provided from September 24, 2019 to November 24, 2019.You asked the Plan to waive the coinsurance for the Zoll Vest. 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 durable medical equipment on the dates of service at issue in this appeal. The Plan states the correct coinsurance 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 20% coinsurance for Durable medical equipment. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a Zoll Vest from September 24, 2019 to November 24, 2019. You have been asked to pay a 20% coinsurance for each date of service for the Zoll Vest, totaling $1826.70 ($608.90 x 3). The Zoll Vest falls within the Durable medical equipment 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 coinsurance forthe Zoll Vest (K0606) provided from September 24, 2019 to November 24, 2019.MAXIMUS Federal Services read your letter and knows that you may have a quality of care concern. MAXIMUS Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Neupogen (Filgrastim) injections.
You asked the Plan to pre-approve the Neupogen (Filgrastim) injections. The Plan denied your request. The Plan says they did not receive information that showed how much of the drug or how often the drug will be given, and need this to determine if it is being used at the approved dosage.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the Neupogen (Filgrastim) injections. Our reviewer says that the Neupogen (Filgrastim) injections are not medically reasonable and necessary for the enrollee. Our physician reviewer found the records support that the enrollee is receiving palliative chemotherapy. Our reviewer found that the documentation does not provide a diagnosis, dosage or treatment schedule for the requested medications. Our physician reviewer also found that, 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 the Neupogen (Filgrastim) injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Neupogen (Filgrastim) injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site
(D4266) and bone replacement graft for ridge preservation - per site (D7953) performed on January 6, 2020.
You asked the Plan to pay for the dental services. You say that you were advised by your Plan representative
that these services would be covered. The Plan denied your request. The Plan says the services are not a
covered benefit under the plan. The Plan states they listened to all calls between you and the Plan and you were
not given misinformation.
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.
Review of the file show that guided tissue regeneration - resorbable barrier, per site (D4266) and bone
replacement graft for ridge preservation - per site (D7953) were performed on January 6, 2020. The services
are excluded in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we decided
that the Plan does not have to pay for guided tissue regeneration - resorbable barrier, per site (D4266) and bone
replacement graft for ridge preservation - per site (D7953) performed on January 6, 2020.