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

We decided that the Plan does not have to waive the copayment for a specialist office visit and coinsurance for
an injection provided by a participating provider on January 21, 2021.

You asked the Plan to waive the copayment for a specialist office visit and coinsurance for an injection. You
say that you do not agree with these charges. You say that you are on a fixed income. The Plan denied your
request. The Plan says the correct charges have 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). Your contract with the Plan clearly says that you must pay a $40
copayment and a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a $40 copayment for a specialist office visit and a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $3,319.05. The amount you are being asked to pay for an injection is $663.81 ($3,319.05 x 20% = $663.81. The total amount you are being asked to pay is $703.81 ($663.81 + $40 = $703.81). A specialist office visit falls within the physician/practitioner services/specialist benefit category and an injection falls within the Medicare Part B prescription drugs 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 specialist office visit and coinsurance for an injection provided by a participating on January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested device is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a home ventilator. Our reviewer says that the documentation supports that the requested ventilator is medically reasonable and necessary. Our physician reviewer found the enrollee has a diagnosis of amyotrophic lateral sclerosis (ALS). The enrollee has worsening chronic respiratory failure related to ALS, which is a covered diagnosis. A ventilator provides functionality beyond BiPAP that is, or soon will be, important for this enrollee, including the use of "sip and puff" ventilation while awake. Therefore, the enrollee does meet criteria for the requested device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have been met. Therefore, we decided that the Plan has to pre-approve a home ventilator.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis (L3908) provided on September 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the orthosis. You say that you feel that your services should be covered. 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 wrist hand orthosis (L3908) provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 13, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the place of service. 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 6, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 physician services provided on October 6, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 27, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services not payable as 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. We find that the laboratory services are not supported in the medical record. Specifically, coverage is denied when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. 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 pay for the laboratory services provided on July 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid-19 test provided on October 15, 2020.

You asked the Plan to pay for the laboratory service. You say that this service should be reimbursed in the amount that equals the cash price for such service as listed by the provider on a public internet website, or such plan or issuer may negotiate a rate with such provider for less than such cash price. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Covid-19 test provided on October 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for contrast material (Q9967) provided on October 21, 2020.
You asked the Plan to pay for contrast material. You say that this is documented in the records. The Plan denied your request. The Plan says this 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 Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. We find that CPT code Q9967 is not supported in the medical record. Specifically, the dosage is not documented in the records. Without this information, this code cannot be verified. Based on this information,
we decided that Medicare rules for coverage of contrast material have not been met. Therefore, we decided that the Plan does not have to pay for contrast material (Q9967) provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on December 7, 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 99152 is not supported and 99153 is 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 99152 is Moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of the presence of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate professional component payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on December 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to change the coinsurance for the specialist services rendered on January 20, 2020.
You asked the Plan to change the coinsurance for these services. You say that the services should be processed as in-network. The Plan denied your request. The Plan says the coinsurance 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 50% of the Medicare-allowed amount for out-of-network specialist visits for Medicare-covered services.
Review of the file shows that you received specialist services from an out-of-network provider on January 20, 2020. You have been asked to pay 50% of the Medicare-allowed amount for these services, for a total of $32.51. These services fall within the out-of-network specialist visits for Medicare-covered 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 change the coinsurance for the specialist services rendered on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foam dressing with item code A6212.
You asked the Plan to pre-approve foam dressing. You say that you need this to keep your wound clean. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because you do not meet the coverage criteria for foam dressing and there was no order from your treating physician.
The Plan follows Medicare rules. Medicare rules state that foam dressings are covered when used on full thickness wounds with moderate to heavy exudate. 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 foam dressing. Our reviewer says that you do not meet the Medicare criteria for this foam dressing. Our physician reviewer found you were receiving basic wound care following surgery. There are no documented full thickness wounds with moderate to heavy exudate in your recent records to justify foam dressing. Other dressings may be considered if needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of foam dressing have not been met. Therefore, we decided that the Plan does not have to pre-approve foam dressing with item code A6212.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on January 25, 2021.

You asked the Plan to waive the copayment for a spinal canal injection. You say that you were not informed that you would owe a 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 $225 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay a $225 copayment for a spinal canal injection. A spinal canal injection 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 for a spinal canal injection provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee arthroscopy services coded 29876 provided on September 16, 2020.

You asked the Plan to pay for the knee arthroscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 29876 is arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral).

We find that CPT code 29876 is not supported in the medical record. Specifically, the operative report did not include documentation of surgical knee arthroscopic major synovectomy, of 2 or more compartments (medial or lateral); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the knee arthroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the knee arthroscopy services coded 29876 provided on September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) received August 28, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that this was a standard evaluation by a new dentist and should be covered. The Plan denied your request. The Plan says the requested service exceeds the benefit frequency limitation.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Plan has submitted evidence that you last received this service (D0150) on November 29, 2018, which the Plan provided coverage. You are not eligible for coverage of this
service again until 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) received August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 19, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 19, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for ophthalmic biometry provided on October 2, 2020.
You asked the Plan to pay for ophthalmic biometry. You say that the medical records were reviewed incorrectly. The Plan denied your request. The Plan says that the medical records were amended for the purpose of gaining reimbursement and therefore cannot be accepted.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records have been reviewed and the Plan has not clearly explained where in the records they believe the amendment occurred. Therefore, we decided that the Plan has to pay for ophthalmic biometry provided on October 2, 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 pay for the drug testing rendered on May 8, 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. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 8, 2020.