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

We decided that the Plan does not have to pay for the outpatient office visit (99213) skin tag removal (11200)
provided on September 4, 2020, by an OON provider.
You asked the Plan to pay for the office visit. You say that the medical records provided support the necessity
of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical
services from an in-network provider with the exception being urgent or emergent services. Non-emergent
services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visit (99213) skin tag removal
(11200) provided on September 4, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 13, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code. We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed with POS code 12 for a home setting; however, this POS code is not appropriate for the billed services. 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 office visit rendered on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.
You asked the Plan to pre-approve a seat lift chair. You say that you cannot get up when you sit down. The Plan denied your request. The Plan says that a seat lift chair is not a covered benefit.
The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism.
Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the head or brain (70450) performed on January 14, 2021.
You asked the Plan to waive the copayment for a CT scan of the head or brain. You say that you should not have to pay the copayment for a service you did not want. 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 $225 copayment for advanced imaging services (not including X-rays). You have been asked to pay a $225 copayment for a CT scan of the head or brain. A CT scan of the head or brain 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 a CT scan of the head or brain (70450) performed on January 14, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on December 13, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis 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 emergency room (ER) services rendered on December 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D assay testing provided on December 16, 2020.
You asked the Plan to pay for Vitamin D testing. You say that you reached your out-of-pocket limit so should not be responsible for this amount. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered for the diagnosis code billed.
The Plan must follow Medicare rules. Medicare rules say that Vitamin D assay testing is not covered for diagnosis code R53.83. We looked at the file and Medicare rules. This test is not covered by Medicare for the diagnosis billed. You were given prior notice that this testing may not be covered and indicated that you understood you may be responsible for the entire cost of the service. The out-of-pocket maximum only applies to covered services; therefore, it would not apply to this non-covered test. Based on this information, we decided that Medicare rules for coverage of Vitamin D testing have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D assay testing provided on December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided from March 14, 2020, to March 21, 2020.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that this was an emergency situation and you would not be allowed to leave unless you received the surgery.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 days 1-5 for inpatient hospital care. You had an inpatient hospital stay from March 14, 2020, to March 21, 2020. Therefore, you are responsible to pay a $325 copayment for days 1-5 (March 14, 2020, to March 18, 2020). $325 (copayment) x 5 (inpatient days) = $1,625. You have been asked to pay the total copayment amount of $1,625 for an inpatient hospital stay. An inpatient hospital stay falls 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 foran inpatient hospital stay provided from March 14, 2020, to March 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on March 31, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that the enrollee has never had to pay in the past and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. The enrollee received a Medicare Part B drug on March 31, 2021. The allowed amount is $815.40 and 20% of that is $163.08.
The enrollee has been asked to pay $163.08 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient office visit (99202) provided February 2, 2021.You asked the Plan to waive the copayment forthe office visit. You say that you do not understand why you are being charged $45 every time you need to have your toenails cut. You are a diabetic making less than $17,000 a year.The Plan denied your request. The Plan says the claim was processed with the correct copay applied per the Evidence of Coverage.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 $45 copayment for physician specialist services. You have been asked to pay $45 copayment for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient office visit (99202) provided February 2, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on August 21, 2020.
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. Medicare rules say that claims must be billed with the appropriate place
of service (POS) code.
We looked at the file and Medicare rules. The file shows that the procedure codes at issue were billed with POS
code 15 for a mobile unit; however, the file shows that this is not the appropriate setting for these services.
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 testing services rendered on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for DME provided on February 24, 2021.
You asked the Plan to reduce the coinsurance for DME. You say that you were not aware you would owe such a high amount and disagree with the charges. 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 20% coinsurance for DME and related supplies. You received DME on February 24, 2021. The total allowed amount is $2,500 and 20% of that is $500.
You have been asked to pay the total coinsurance amount of $500 for DME. DME falls within the 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 reduce the coinsurance for DME provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on December 23,
2020.
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 code 99239 is 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 99239 is hospital discharge day management; more than 30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of
discharge services of more than 30 minutes. 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
hospital discharge services rendered on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management service before and/or after direct patient care, first hour (99358) prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (99359) telemedicine 21-30 minutes (99443) provided on February 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the evaluation and management services. You say that your doctor provided medically necessary services in good faith and in return you are expecting reimbursement. The Plan denied your request.
The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 prolonged evaluation and management service before and/or after direct patient care, first hour (99358) prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (99359) telemedicine 21-30 minutes (99443) provided on February 8, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on February 3,
2020, to February 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you received a referral from your
primary care provider. 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. The Plan has confirmed that they reached out to your primary care provider regarding the
referral status but were unable to get in contact with them. 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 February 3, 2020, to February 17, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered on March 13, 2021.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 71045 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71045 (chest x-ray) and 32557 (percutaneous pleural drainage with insertion of catheter and imaging guidance). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32557. Code 71045 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered on March 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted ambulance service (A0999) provided onOctober 14, 2020.You asked the Plan to pay forunlisted ambulance service (A0999). The Plan denied your request. The Plan says that there is no documentation of what this code represents. A review of the transport record does not indicate use of supply or other item that wouldjustify this billed service. The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance services includes a base rate payment plus a separate payment for mileage.This payment covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport. We looked at the file and Medicare rules.Medicare says that payment under the fee schedule for ambulance services includes a base rate payment plus a separate payment for mileage. Therefore, we decided that the Plan does not have to pay forthe unlisted ambulance service (A0999) provided on October 14, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay fordrug testing (G0483) provided on November 5, 2020.You asked the Plan to pay fordrug testing. You say that the billed drug classes are supported by the records.The Plan denied your request. The Plan says that the records show only 11 drug classeswere 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 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 andvariations 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 find that CPT code G0483 is supported in the medical record. Specifically, the submitted medical records show that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have been met.Therefore, we decided that the Plan has to pay fordrug testing (G0483) provided on November 5, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on January 13, 2021, by an out-of-network provider.
You asked the Plan to pre-approve the laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service is considered experimental/ investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the laboratory services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date the evidence is insufficient to determine the effects of the technology on health outcomes.
In addition to the aforementioned general limitations for expanded/comprehensive genomic testing/profiling, this testing from the provider does not meet the criteria specified in CMS' NCD for Next Generation Sequencing (NGS). Specifically, the testing under review does not have FDA approval or clearance as a companion in vitro diagnostic, as the NCD requires in its coverage criteria. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on January 13, 2021, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 6, 2021 to January 9, 2021.

You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct type of bill.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim was not billed with a valid type of bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 6, 2021 to January 9, 2021.