Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with removal of a tumor (45385) provided by the practice on July 23, 2019.

You asked the Plan to waive the copayment for a colonoscopy with removal of a tumor. You say that it was a preventive colonoscopy and you are not having any health issues at this time. The Plan denied your request. The Plan says outpatient surgery services have a $200 copayment. The Plan also says that during your procedure you were treated for or monitored for an existing condition.

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 $200 copayment for outpatient surgery services. 

You have been asked to pay a $200 copayment for a colonoscopy with removal of a tumor. This service falls within the outpatient surgery services benefit category. The record shows that while you were scheduled for a preventive service, during the procedure, a tumor was removed. This is considered an existing medical condition and that is why the copayment applied. 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 colonoscopy with removal of a tumor (45385) provided by the practice on July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 3, 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 documentation submitted does not include definitive laboratory results for 22 or more drug classes to support the coding criteria for G0483.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

In this case, the definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."

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 based on the records provided HCPCS G0483 was not coded correctly. Our physician reviewer found based on the records provided only 17 drug classes were tested

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 drug testing services provided to the enrollee on April 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a suprahyoid lymphadenectomy (38700) provided by the physician on April 25, 2019.You asked the Plan to pay for a suprahyoid lymphadenectomy. You say that this was medically necessary.The Plan denied your request. The Plan says surgical assistants are not recognized for payment by Medicare or the Plan.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay fora suprahyoid lymphadenectomy (38700) provided by the physician on April 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom ramp.You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 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 pay for custom ramp.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97110, 97530, and 97112) provided on August 14, 2019.You asked the Plan to pay for occupational therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, or that the services could be safely and effectively performed only by a therapist during the date at issue. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for occupational therapy services (97110, 97530, and 97112) provided on August 14, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerebral perfusion imaging provided on July 16, 2019 billed with code 0042T.You asked the Plan to pay for the cerebral perfusion imaging. You say that the imaging report was submitted to support medical necessity.The Plan denied your request. The Plan says the rendered services are not covered as they are not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that the services described by Category III CPT codes, such as 0042T, are not considered medically necessary.Therefore, we decided that the Plan does not have to pay for the cerebral perfusion imaging provided on July 16, 2019 billed with code 0042T.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve light weight portable oxygen concentrator .You asked the Plan to pre-approve the DME. You say that you would be better able to complete household tasks with a lightweight oxygen concentrator and would exchange the Philips SimplyGo for the lighter unit. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Per the Medicare guidelines, items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. Additional expenses for reasons of added convenience are not considered reasonable. Based on the information we received, there is no evidence that you are able to tolerate a pulse-dose conserver regulator delivery system or that you have a medical need for a light weight portable oxygen concentrator. Additionally, no more than 1 unit of service for stationary oxygen contents and/or portable oxygen contents per month are billable. Therefore, we decided that the Plan does not have to pre-approvelight weight portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99307) provided on June 14, 2019 by out of network provider.You asked the Plan to pay for nursing facility care. You say that this service was medically necessary.The Plan denied your request. The Plan says this service was not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for nursing facility care (99307) provided on June 14, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 23, 2019 by out of network provider. You asked the Plan to pay for laboratory testing. You say that the referring physician is in-network with the Plan, and the enrollee was never informed of where the testing would be performed.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.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 payfor these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on May 23, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97115, and 97112) provided on August 13, 2019.You asked the Plan to pay for physical therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 physical therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, or that the services could be safely and effectively performed only by a therapist during the date at issue.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for physical therapy services (97110, 97115, and 97112) provided on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the test strips, lancets, control solution, and batteries provided by the practice from August 6, 2019 to October 25, 2019.
You asked the Plan to pay fo rthe test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe test strips, lancets, control solution, and batteries provided by the practice from August 6, 2019 to October 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from June 18, 2019 through July 2, 2019.You asked the Plan to waive the copayment for the SNF services. You say that you cannot afford to pay this bill.The Plan denied your request. The Plan says cost sharing is a contractual agreement of the plan and cannot be waived.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 $160 copayment for days 21-62 of SNF care. You have been asked to pay a $1,280 copayment for the SNF services. The file indicates you were in the SNF for 28 days. You were charged a copayment of $160 for days 21-28 of SNF care. 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 skilled nursing facility (SNF) services provided from June 18, 2019 through July 2,2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided by the practice on March 9, 2019.You asked the Plan to pay for lab tests. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for these services is correct, because there is not a valid physician order for these tests and the tests were ordered by telemedicine which is a Medicare-prohibited action.The Plan must follow Medicare rules. Medicare rulessay that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include an order or clear intent to order the specific lab services from the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay for laboratory testing provided by the practice on March 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fo rthe nerve conduction studies provided on July 16, 2019 billed with code 95910.You asked the Plan to pay forthe nerve conduction studies as billed. You say that the nerve conduction studies are correctly coded and should be paid.The Plan denied your request. The Plan says the report does not indicate that 7-8 nerves were tested.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 95910 is Nerve conduction studies; 7-8 studies.We find that CPT code 95910 is not supported in the medical record. Specifically, the report does not document studies being performed on 7 to 8 nerves. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies as billed have not been met.Therefore, we decided that the Plan does not have to pay for the nerve conduction studies provided on July 16, 2019 billed with code 95910.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an extracranial bilateral study (93880) and lower extremity bilateral study (93925) provided on July 17, 2019 by out of network provider.You asked the Plan to pay for the extracranial bilateral study and lower extremity bilateral study. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says non-emergent services provided by a non-contracted provider are not covered when a contracted provider is able to provide the 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 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 an extracranial bilateral study (93880) and lower extremity bilateral study (93925) provided on July 17, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic esophagogastroduodenoscopy (an EGD), including collection of a specimen (43235) provided by the practice on July 11, 2019.You asked the Plan to waive the copayment foran EGD. You say that on July 11, 2019 you had a colonoscopy and endoscopy at the practice. You say that you are now receiving a bill and believe you should not be responsible for this.The Plan denied your request. The Plan says you have certain coverage. That contract states that outpatient surgery services received in an ambulatory surgical center have a $200 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 $200 copayment for outpatient surgery services. You have been asked to pay a $200 copayment for an EGD. This service falls within the outpatient surgery services benefit category in an ambulatory surgical center.The record indicates that the services were performed due to gastritis without bleeding (K2960), personal history of colonic polyps (Z86010), and rectal polyps(K621). This is the reason that a diagnostic colonoscopy copayment applied.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 fora diagnostic esophagogastroduodenoscopy (an EGD), including collection of a specimen (43235) provided by the practice on July 11, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for therapeutic activities (97530) and neuromuscular reeducation (97112) provided by the physician from July 17, 2019 through August 28, 2019.You asked the Plan to waive the copayment for physical therapy (PT). You say that prior to going you checked your coverage for the services. They told you that you had 8 visits with a $0 copayment. Later you found out that you would be billed $40 for each visit. You say you are on a fixed income and should not be responsible for these bills.The Plan denied your request. The Plan says outpatient rehabilitation services have a $40 copayment per day.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 per day for outpatient rehabilitation services. You have been asked to pay a $40 copayment for physical therapy (PT).This service falls within the outpatient rehabilitation services benefit category($40 x 4 visits = $160). 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 fortherapeutic activities (97530) and neuromuscular reeducation (97112) provided by the physician from July 17, 2019 through August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora diagnostic mammography (77066), digital breast tomosynthesis (G0279), and an ultrasound (76642) provided on July 17, 2019 by out of network provider. You asked the Plan to pay fora diagnostic mammography, digital breast tomosynthesis, and an ultrasound. You say that your physicians should be in network.The Plan denied your request. The Plan says these were out-of-network services provided without 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 fora diagnostic mammography (77066), digital breast tomosynthesis (G0279), and an ultrasound (76642) provided on July 17, 2019 by out of network provider.Your complaint about network status is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.