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 you had with your primary care provider (PCP) on April 30, 2021.

You asked the Plan to waive the copayment for the PCP visit. You say that this visit was for your annual physical, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because you received services that addressed a medical condition during this visit, the office visit copayment applies.

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 visits with your PCP.

You have been asked to pay a $10 copayment for the PCP visit. In order to qualify for no copayment under the annual physical exam benefit, the services you receive must be limited to those covered as part of an annual physical. According to your Evidence of Coverage, the annual physical exam includes the following services: a bodily systems exam, measurement and recording of vital signs, a complete medication review, and a review of recent hospitalizations. We looked at your medical records for this date of service. In addition to the services covered under the annual physical exam, the medical records show that you were assessed for acquired hypothyroidism and prescribed a new medication with a new dosage. Because this assessment is beyond the scope of the annual physical exam, the PCP office visit copayment applies. 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 you had with your primary care provider (PCP) on April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy (77336), stereoscopic x-ray guidance (G6002), and the proton treatment delivery (77523) rendered by the out-of-network (OON) provider on February 2, 2021.
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 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 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 continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy (77336), stereoscopic x-ray guidance (G6002), and the proton treatment delivery (77523) rendered by the out-of-network (OON) provider on February 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel provided on June 15, 2020.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel. You say that the medical records provided support the services billed. The Plan denied your request. The Plan says the Place of Service (POS) code billed was inappropriate for the procedure in dispute.
The Plan must follow Medicare rules. Medicare rules say that POS code 31 should be used with services for patients in a Part A covered stay and POS code 32 should be used with services for beneficiaries in a noncovered stay. Medicare rules also say that, when the enrollee is in a Medicare-covered SNF stay and when POS code 31 is being appropriately billed, any associated transportation and setup costs would be subject to consolidated billing and must be included on the SNF's Part A bill for the resident's covered stay. We looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed with a POS code of 31. This POS code represents a covered SNF stay and would mean that transportation of portable x-ray equipment would be included in payment for the covered SNF stay. However, the Plan states that the enrollee's SNF stay in this case is non-covered. This would mean that 32 would have been the appropriate POS code to bill in this case. Transportation of portable x-ray equipment is not separately payable when billed with a 31 POS code. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel have not been met. Therefore, we decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel provided on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in the setting of chronic low back pain due to degenerative disc disease has not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure for low back pain treatment. Our physician reviewer found that the enrollee's condition does not meet criteria for these services.

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 the Intracept procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99204) and dilated macular exam (G9974) provided on April 19, 2021.
You asked the Plan to waive the copayment for the office visit and dilated macular exam. You say that you would like reconsideration because you went to the office for glasses and did not want to see the doctor. The Plan denied your request. The Plan says the vision examination you had with this provider was billed correctly as a medical vision exam.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for a Medicare-covered exam to diagnose and treat diseases or conditions of the eye. You have been asked to pay a $45 copayment for the office visit and dilated macular exam. The office visit and dilated macular exam falls within the Vision 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 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 (99204) and dilated macular exam (G9974) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for homocysteine (CPT code 83090) provided to the enrollee on November 9, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the obtained homocysteine level. Homocysteinemia
may be due to a genetic predisposition to abnormal activity in the same pathways as homocystinuria. Nutritional and environmental factors, as well as specific medications, may worsen this abnormality and provoke symptoms. An increased homocysteine level is associated with a higher risk of strokes. Carotid stenosis appears to have a graded response to increased levels of homocysteine. Increased carotid plaque thickness has been associated with high homocysteine and low B-12 levels. The review has determined that the items/services at issue in this case were not medically reasonable or necessary, and supported by the medical records. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for homocysteine (CPT code 83090) provided to the enrollee on November 9, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH services are appropriate and
medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to
an LTACH are not met, and the enrollee can receive the necessary care in another setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where they are currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device
provided February 1, 2021.
You asked the Plan to pay for the CPAP device. You say that you would like this claim reprocessed for
payment. The Plan denied your request. The Plan says this provider is not certified with Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure
(CPAP) device provided February 1, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an alcohol and drug assessment (H0001) provided on April 27, 2021.
You asked the Plan to pay for an alcohol and drug assessment. You say that this is an appropriate code. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 H0001 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an alcohol and drug assessment have not been met. Therefore, we decided that the Plan does not have to pay for an alcohol and drug assessment (H0001) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the virtual visit you had with a nurse practitioner from your primary care doctor's office on January 30, 2021.
You asked the Plan to waive the copayment for the virtual visit. You say that you do not recognize the provider. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you signed a Chronic Care Agreement form that indicates that you agreed to receive these telehealth services from the nurse practitioner.
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 $5 copayment for primary care visits, including virtual check-ins. The medical records from this date of service confirm that you had a virtual visit with this provider. The
records show that this was a chronic care management visit. You have been asked to pay a $5 copayment for the virtual visit. 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 virtual visit you had with a nurse practitioner from your primary care doctor's office on January 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), fluoride application (D1208), complete series of x-rays (D0210) and dental cleaning (D1110) provided on April 19, 2021.
You asked the Plan to pay for the dental services. You say that you changed dental providers on this date and did not realize that there were any provider exclusions with your plan. You are on a fixed income and this bill would be a financial burden. The Plan denied your request. The Plan says the provider in this case has opted out of Original Medicare. The Plan does not cover dental services received from providers who do not accept Medicare payments. Therefore, payment for these services is denied.
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 can cover dental services when they are received from a licensed dental provider who accepts
Medicare patients in the United States and has not opted out of Original Medicare.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a
provider who does not participate in Original Medicare are not among those covered under this benefit.
Documentation shows that at the time services were rendered, the provider in question did not participate in the
Medicare program or accept Medicare payment. Therefore, we decided that the Plan does not have to pay for
the comprehensive oral evaluation (D0150), fluoride application (D1208), complete series of x-rays (D0210)
and dental cleaning (D1110) provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a gastroenterologist on April 16, 2021.

You asked the Plan to waive the copayment for the gastroenterology visit. You say that you did not have to pay a copayment when you first got on Social Security. You said that all that you and this specialist did was sit and talk about your health issues and no procedures were performed. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for visits with a specialist. 

You have been asked to pay a $30 copayment for the gastroenterology visit. The gastroenterology visit falls within the visits with a specialist 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 you had with a gastroenterologist on April 16, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a catheter replacement (36581-78) with fluoroscopic guidance (77001) provided on June 26, 2020.
You asked the Plan to pay for a catheter replacement with fluoroscopic guidance. You say that this was medically necessary. The Plan denied your request. The Plan says that code 36581 is included in the global surgical package of the procedure performed on June 16, 20210 unless billed with modifier -78, and code 77001 is an add-on code that cannot be paid when the primary procedure is denied.
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 states that code 36581 cannot be paid without modifier -78, but the records show that it was billed with modifier -78. The Plan has not provided sufficient information to support this denial reasoning. Because code 77001 was denied based on the primary code 36581 being denied, it must also be paid. Therefore, we decided that the Plan has to pay for a catheter replacement (36581-78) with fluoroscopic guidance (77001) provided on June 26, 2020.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient psychiatric visits provided on March 2, 2021, to March 30, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient psychiatric visits. You say that this request is medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient psychiatric visits provided on March 2, 2021, to March 30, 2021 by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 21, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee was under hospice care on this date of service.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 21, 2021.