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

We decided that the Plan does not have to pay for office visit services provided to the enrollee on February 18, 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 Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.
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 office visit services provided to the enrollee on February 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 22854 provided on August 21, 2019.
You asked the Plan to pay for CPT code 22854. You say that the medical records support the billing of CPT code 22854. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 22854.
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 22854 is Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure). 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 CPT code 22854. Our reviewer says that the medical records do not support the billing of CPT code 22854. Our physician reviewer found the documentation provided for review does not support the corpectomy code. It cannot be used. No corpectomy is documented. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 22854 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 22854 provided on August 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom ankle foot orthosis (AFO).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an AFO is 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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you are wheelchair-bound and non-ambulatory. Given that you are not able to independently ambulate, the criteria for the AFO are not met. The AFO is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom ankle foot orthosis (AFO).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on November 16, 2019.You asked the Plan to pay forthe ambulance services. You say that the enrollee could not have been transported safely by any other means.The Plan denied your request. The Plan says the service is notcovered as indicated by the modifier submitted.Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.   In this case, the provider submitted their claim for payment with a GY modifier that indicates that the services provided were non-covered by Medicare.  The ambulance provider has submitted a claim that cannot be paid based on Medicare billing guidelines. Because the provider is out-of-network, the plan cannot over-ride the claim.Therefore, we decided that the Plan does not have to pay forservices provided on November 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from October 2, 2019 to October 30, 2019.
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 claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered with code 85. We looked at the file and Medicare rules. The file shows that the home health claims were not billed with the required FIPS code. 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 pay for the home health services rendered from October 2, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture treatment (97813) provided by the provider from October 25, 2019 to December 5, 2019.
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 these services are not a covered benefit under
your contractual policy.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have
to pay for the acupuncture treatment (97813) provided October 25, 2019 to December 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray on December 20, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the additional 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 $50 copayment for each X-ray. You have been asked to pay the allowed amount of $30.61, which is less than the $50 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November 14, 2019.
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery. The Plan denied your request. The Plan says payment for the services are included in the payment to the facility.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided to the enrollee on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture.
You asked the Plan to pre-approve a complete lower denture. The Plan denied your request. The Plan says that you have met the plan limits for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a complete lower denture once every five years. We looked at the file and Medicare rules. The file confirmed you received a complete lower denture on August 15, 2019. Based on this information, we decided that the Plan's rules for coverage of a complete lower denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 18, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered to you on
June 20, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 per visit for Medicare-covered specialty care services.
Review of the file shows that you received specialist services on June 20, 2019. You have been asked to pay a
$35 copayment for these services. These services fall within the Medicare-covered specialty care 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 the specialist services rendered
to you on June 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered to you on
November 25, 2019.
You asked the Plan to waive the copayment for these services. You say that you should not be responsible for
the copayment. The Plan denied your request. The Plan says the copayment was 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 $15
copayment for each Medicare-covered lab test.
Review of the file shows that you received laboratory services on November 25, 2019. You have been asked to
pay a $15 copayment for these services. These services fall within the Medicare-covered lab test 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 laboratory services rendered to you on
November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 43235 and G0500 provided on September 30, 2019.
You asked the Plan to pay for CPT codes 43235 and G0500. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 43235 is Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). The CPT Code Manual definition of code G0500 is Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate). We find that CPT codes 43235 and G0500 are not supported in the medical record. Specifically, the documentation provided indicates the duodenum was not examined and the procedure was aborted. The documentation does not show that moderate sedation was provided. Based on this information, we decided that Medicare rules for coverage of CPT codes 43235 and G0500 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 43235 and G0500 provided on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron Emission Tomography (PET) scan (78815) provided on September 18, 2019.
You asked the Plan to pay for the PET scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. These services were available in-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 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 Positron Emission Tomography (PET) scan (78815) provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
September 20, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you had discussed
making an appointment but never did. You say you are still be charged. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for each in-network Medicare-covered visit with a specialist.
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical
record shows you were seen for a follow-up visit on September 20, 2019 with this provider.
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 specialist office visit provided on September 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the echocardiography provided on April
24, 2019.
You asked the Plan to waive the coinsurance for the echocardiography. You say that your doctor recommends
an echocardiography every year. You say that this should be considered preventive. The Plan denied your
request. The Plan says the coinsurance 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 20%
coinsurance for other diagnostic procedures and tests.
You have been asked to pay $15.39, which is 20% of the allowed amount for the echocardiography. The
allowed amount is $76.94 (20% x $76.94 = $15.39). The echocardiography falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The echocardiography is considered a
diagnostic test. 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 echocardiography provided on April
24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 17, 2019.
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 procedure codes J2182 and 96372 are 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 J2182 is injection, mepolizumab, 1 mg. The definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. We find that CPT codes J2182 and 96372 are not supported in the medical record. Specifically, the documentation shows that an injection of Nucala was given, but there is no detail of administration to support code J2182. There is no documentation of detailed administration of a therapeutic, prophylactic, or diagnostic injection to support code 96372. 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 pay for the services rendered to the enrollee on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature, cup holder or bag hooks.
You asked the Plan to pre-approve power wheelchair power seat elevation feature, cup holder and bag hooks. You say that the enrollee needs these accessories. The Plan denied your request. The Plan says the power seat elevation feature, cup holder and bag hooks do not serve a medical purpose and are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature, cup holder or bag hooks.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Computed Tomography (CT) of the Maxillofacial area (70486) provided on December 18, 2019 by the provider.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $275 copayment for Advanced Imaging Services. You have been asked to pay a $134.40 copayment for the CT scan. The CT scan falls within the Advanced Imaging Services benefit category. The Medicare allowable amount is less than the $275 copayment stipulated in the contract. 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 Computed Tomography (CT) of the Maxillofacial area (70486) provided on December 18, 2019 by the provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on September 20, 2019 by an out of network (OON) provider.