Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implants (D6010) for teeth #s 3 and 19 provided April 29, 2021.  You asked the Plan to pay for the endosteal implants. You say that this service should be covered. The Plan denied your request. The Plan says this service does not meet criteria for coverage.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers implants when used to hold a complete denture.     We looked at the file and Medicare rules. In this case the implants provided do not appear to have been provided to hold complete dentures. Based on this information, we decided that the Plan's rules for coverage of the endosteal implants have not been met. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implants (D6010) for teeth #s 3 and 19 provided April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory services (81001, 87086) provided on July 28, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.  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 $30 copayment for lab services and diagnostic procedures/tests performed in an outpatient hospital facility.    You have been asked to pay $9.60 ($2.74 + $6.86) for the laboratory services performed in an outpatient hospital facility. This is the Plan's allowed amount for these services, which is less than the applicable copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services (81001, 87086) provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on September 27, 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 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, single view) and 71046 (chest x-ray, two views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. 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 for the chest x-ray rendered on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the technical component of neuromonitoring services (95861-TC, 95939-TC, 95868-TC, 95938-TC) provided on May 28, 2021.  You asked the Plan to pay for the technical component of neuromonitoring services. You say that this was billed correctly. The Plan denied your request. The Plan says this cannot be paid because the enrollee was an inpatient.  The Plan must follow Medicare rules. Medicare rules say that Medicare may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians' radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made to the hospital as a provider service.    We looked at the file and Medicare rules. The services at issue were provided to an inpatient hospital patient, meaning the technical component cannot be paid. Based on this information, we decided that Medicare rules for coverage of the technical component of neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the technical component of neuromonitoring services (95861-TC, 95939-TC, 95868-TC, 95938-TC) provided on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on April 30, 2020.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic exercise (97110) provided January 7, 2021 to July 8, 2021.  You asked the Plan to pay for the chiropractic service. You say that you have been going to a chiropractor off and on since 1988. The claims submitted by the doctor had been paid previously and are now being denied and you do not know why. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic exercise (97110) provided January 7, 2021 to July 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided on June 10, 2019, through August 8, 2019.  You asked the Plan to pay for the home health services. You say that you would like reconsideration because the documentation supports the services billed. The Plan denied your request. The Plan says the occupational therapy notes are missing comparison of the resultant measurements to prior assessment measurements as required.   The Plan must follow Medicare rules. Medicare rules say that the therapist must document in the clinical record the measurement results along with the therapist's determination of the effectiveness of therapy, or lack thereof.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record submitted does not document the measurement results along with the therapist's determination o the effectiveness of therapy, or lack thereof. Therefore, we decided that the Plan does not have to pay for the home health services provided on June 10, 2019, through August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on July 14, 2021.  You asked the Plan to pay for the IV tubing extension set (S1015) and infection control supplies (S8301). You say that a standard list of durable medical equipment, supplies and medications are always provided or made available for emergencies. You say that this policy was implemented to ensure to meet the standard of care and the claim should be reprocessed for appropriate payment. The Plan denied your request. The Plan says CPT code 91999 was overturned. The Plan also says CPT code S1015 and S8301 are not valid for Medicare purposes.  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 S1015 is IV tubing extension set. The CPT Code Manual definition of code S8301 is infection control supplies, not otherwise specified.  We find that CPT code S1015 and S8301 are not supported in the medical record. Specifically, CPT code S1015 and S8301 have a status indicator of I. This means that CPT code S1015 and S8301 are not valid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension set (S1015) and infection control supplies (S8301) have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on July 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the individual psychotherapy (90832) services provided August 17, 2021.  You asked the Plan to pay for the psychotherapy services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the listing of a referring provider on the claim does not satisfy the documentation criteria.  The Plan must follow Medicare rules. The rules say that if consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. This does not apply if the physician referred the patient to the clinical psychologist.   We looked at the file and Medicare rules. The submitted claim includes a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for the individual psychotherapy (90832) services provided August 17, 2021.   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 waive the coinsurance for laboratory services provided on August 16, 2021.  You asked the Plan to waive the coinsurance for the laboratory services. You say that you made this appointment as part of your annual physical exam. The Plan denied your request. The Plan says the correct coinsurance 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 $0 copayment for one routine physical exam each year. This does not include lab tests, radiological diagnostic tests, or non-radiological diagnostic tests.   Your contract with the Plan also clearly says that you must pay a 10% coinsurance for lab services.  Test Allowed Amount 10% Coinsurance Blood Test, Lipids $11.94 $1.19 Blood Test, TSH $14.98 $1.50 Complete Blood Cell Count $6.93 $0.69 Blood Test, Comprehensive $9.42 $0.94 Total:  $4.32  You have been asked to pay $4.32, which is 10% of the allowed amount for the laboratory services. The laboratory services fall 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 coinsurance for laboratory services provided on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the EGD provided on September 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the EGD. You say that the claim was denied incorrectly for lack of referral. The Plan denied your request. The Plan says no prior authorization was obtained.  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 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 EGD provided on September 24, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hammertoe repair (28285) and arthrodesis (28755) provided on June 29, 2021.  You asked the Plan to pay for the assistant surgeon services for hammertoe repair (28285) and arthrodesis (28755). You say that the CPT codes on this claim are allowed to an assistant surgeon. You say that the medical records are attached, and the claim should be processed for appropriate payment. The Plan denied your request. The Plan says assistant surgeons are not allowed for these services.    The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 28285 and CPT code 28755. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services for hammertoe repair (28285) and arthrodesis (28755) have not been met. Therefore, we decided that the Plan does not have to pay for the hammertoe repair (28285) and arthrodesis (28755) provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit provided on August 31, 2021.  You asked the Plan to waive the copayment for the office visit. You say that this was an adult routine physical and you should not be liable for an office visit copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment per visit for a primary care physician office visit.   You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/ Practitioner services, including doctor's office visits" benefit category. The medical record shows hearing loss and a knee injection were discussed in addition to the routine physical exam. 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 office visit provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on June 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that you rely on the facility to obtain the authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on June 21, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided October 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to provide additional payment for the surgical tooth extraction. You say that this service is necessary, and the cost is too high. The Plan denied your request. The Plan says the claim has processed correctly according to your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the surgical tooth extraction with 30% coinsurance. If out-of-network providers charge more for a service than what the Plan has agreed to pay, you will be responsible for the difference.    We looked at the file and Medicare rules. In this case the Plan provided documentation showing that you have been requested to pay 30% of the allowed amount for this service ($203 allowed amount x 30% coinsurance = $60.90). Additionally, since services were received OON, you are responsible for the difference between the allowed amount and the amount charged by the OON provider ($300 total cost - $203 allowed amount =$97). This leaves you with a total cost share of $157.90 ($97+$60.90=$157.90). This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rest home visit provided on August 24, 2021 by an out-of-network (OON) provider.  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 services were rendered by an out-of-network provider without prior 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 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 rest home visit provided on August 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for paravertebral facet joint injections (64494-LT and 64494-RT).  You asked the Plan to pay for paravertebral facet joint injections. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this code has a medically unlikely edit (MUE) value of 1 so is not payable for 2 units, and this code is a bilateral code so should be reported with 1 unit of service for a bilateral procedure.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint injections have not been met. This code can be billed with 1 unit for processing through the bilateral surgical procedure payment calculation. Therefore, we decided that the Plan does not have to pay for paravertebral facet joint injections (64494-LT and 64494-RT).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ultrasounds of the pelvis provided from July 14, 2021, to August 2, 2021.  You asked the Plan to waive the copayments for the ultrasounds. You say that you feel that the Plan should cover all expenses related to an outpatient surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for radiological diagnostic services, not including X-rays, performed in a physician's office or at a free-standing facility.   Procedure Copayment per EOC Actual Charge Ultrasound of Pelvis - July 14, 2021 $175 $118.43 Ultrasound of Pelvis - July 26, 2021 $175 $118.43 Ultrasound of Pelvis - August 2, 2021 $175 $118.43 Total:  $355.29  You have been asked to pay $118.43 for each ultrasound, which is less than the $175 copayment for the ultrasounds. The total for the three procedures is $355.29. Ultrasounds fall 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 copayments for ultrasounds of the pelvis provided from July 14, 2021, to August 2, 2021.   Your complaint about the Plan representative informing you that all services are covered when related to outpatient surgery 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.