Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 9, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT codes S1015 and S8301 provided on June 4, 2019.You asked the Plan to pay forCPT codes S1015 and S8301. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.Therefore, we decided that the Plan does not have to pay forCPT codes S1015 and S8301 provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 99205 provided on September 5, 2019.You asked the Plan to pay forCPT code 99205. 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 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 99205 is Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.We find that CPT code 99205 is not supported in the medical record. Specifically, the enrollee was also seen on January 26, 2018 with the same group practice and specialty. The code for a new patient visit is not appropriate in this case as the enrollee is an established patient and not a new patient per Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of CPT code 99205 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 99205 provided on September 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on July 18, 2019 and July 31, 2019.You asked the Plan to pay for the psychotherapy services (90837). 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 psychotherapy services (90837) provided on July18, 2019 and July 31, 2019.Please note the Plan is handling dates of service March 28, 2019, April 4, 2019, and August 9, 2019 under separate appeal, and if denied, the Plan will send to us and a new appeal number will be assigned.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 24, 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 July 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 17, 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 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 are a 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 laboratory services provided on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Genocept Assay testing provided on July 29, 2019 by the out of network provider.You asked the Plan to pay forthe laboratory testing. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee was referred for the services by another out of network provider. The Plan also says the services were not urgent or emergent.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 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 forthe Genocept Assay testing provided on July 29, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided by"the provider" July 31, 2019 to August 2, 2019You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you should have been charged $90 copy for emergency services from 7/31/19 to 08/01/19 and then the $295 copay for the inpatient stay from 08/01/19 to 08/02/19.The Plan denied your request. The Plan says per the plan benefits the cost share 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 $295 copayment each day for days 1-4. for Inpatient Hospital Care. You have been asked to pay $590.00. There is a $295 copayment each day for days 1-4 for the inpatient hospital services. The inpatient hospital services fall 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 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 forthe inpatient hospital services provided by "the provider" July 31, 2019 to August 2, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle x-ray; 2 views (73600) provided.
You asked the Plan to pay for the ankle x-ray; 2 views. You say that the service was performed and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Specifically, the documentation submitted shows that the doctor provided an ankle x-ray with three views. The documentation submitted does not support the billing of an ankle x-ray with two views. Based on this information, we decided that Medicare rules for coverage of the ankle x-ray; 2 views have not been met. Therefore, we decided that the Plan does not have to pay for an ankle x-ray; 2 views (73600) provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe placement of a breast localization device provided by "the provider" on June 24, 2019.You asked the Plan to waive the copayment forthe placement of a breast localization device. You say that you disagree with the surgery 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 $325 copayment for outpatient surgery services provided in an outpatient hospital facility. You received the placement of a breast localization device provided by "the provider" on June 24, 2019.The placement of a breast localization device is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for theplacement of a breast localization device. The placement of a breast localization device 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 forthe placement of a breast localization device provided by "the provider" on June 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 17, 2019 by an out of network provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the service in question.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 notpre-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 forthe medical services provided on February 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on April 26, 2019 billed with code 95941.You asked the Plan to pay for the billed IONM services. You say that this should be paid as medically necessary to be performed during this surgery.The Plan denied your request. The Plan says it was decided to make payment for all services aside from code 95941 which is not valid for Medicare billing.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 95941 is not supported in the medical record. Specifically, this code has a status indicator of "I" meaning it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the billed IONM services have not been met.Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on April 26, 2019 billed with code 95941.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 97161-GPGP, 97124-GP, and 97110-GP provided on April 29, 2019 and May 6, 2019.

You asked the Plan to pay for CPT codes 97161-GPGP, 97124-GP, and 97110-GP. 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 must follow Medicare rules. Medicare rules say modifiers are used to identify therapy services.

In this case, the claim was billed with CPT code 97161 with modifier GPGP. Per Medicare guidelines, no more than one GP modifier is reported on the same service line. Therefore, we find that the Plan does not have to pay for CPT code 97161-GPGP provided on April 29, 2019 and May 6, 2019.

Medicare rules also 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 97124 is Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) and the CPT Code Manual definition of code 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT codes 97124 and 97110 are not supported in the medical record. Specifically, CPT codes 97124 and 97110 are time-based codes; the medical record does not contain the amount of time spent providing each service. It cannot be verified that the requirements for reporting these time-based codes have been met. Therefore, we decided that the Plan does not have to pay for CPT codes 97124-GP and 97110-GP provided on April 29, 2019 and May 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided on January 11, 2019.
You asked the Plan to pay for the orthosis. You say that the first doctor who provided a shoulder sling was issued a fee of $12.09 of which the plan paid $10 leaving you with a $2.09 responsibility and you feel that fee is more reasonable The Plan denied your request. The Plan says the claim processed correctly per the plan benefits.
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 Durable medical equipment (DME) and related supplies. You have been asked to pay $18.22. There is a 20% coinsurance. The plan allowed $91.10. (91.10x.20=18.22) for the orthosis. the orthosis falls within the Durable medical equipment (DME) and related 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 pay for the shoulder orthosis provided on January 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 14, 2019.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 February 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95813 and 95941 provided on March 12, 2019.You asked the Plan to pay for CPT codes 95813 and 95941. 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 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 95813 is Electroencephalogram (EEG) extended monitoring; greater than 1 hour. We find that CPT code 95813 is not supported in the medical record. Specifically, the medical records provided do not show greater than 1 hour of extended monitoring with EEG was provided. Furthermore, CPT code 95941 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.Therefore, we decided that the Plan does not have to pay forCPT codes 95813 and 95941 provided on March 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient specialist visit provided on May 14, 2019.
You asked the Plan to waive the copayment for the outpatient specialist visit. 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 a visit by a cardiology specialist while you were in an outpatient hospital setting. The plan states the correct copayment 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 $40 copayment for specialist visits. We looked at the file and Medicare rules. The file shows you received a specialist visit with a cardiologist during your outpatient hospital stay. You have been asked to pay a $37.04 copayment for the outpatient specialist visit, which is less than the contracted $40 copayment amount. The outpatient specialist visit falls within the Physician/Practitioner 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 outpatient specialist visit provided on May 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on August 19, 2018 to August 23, 2018.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee has a lot of debt with this hospital and cannot afford this amount. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $320 copayment per day for days 1-5. There is a $0 copayment per day for additional days for inpatient hospital care. The enrollee has been asked to pay a $320 copayment per day for days 1-4 for an inpatient hospital stay. The total amount the enrollee is being asked to pay is $1,280 ($320 x 4 days = $1,280). Since an inpatient hospital stay was provided, the correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on August 19, 2018 to August 23, 2018.