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

 We decided that the Plan does not have to pay for the outpatient lumbar fusion procedure coded as 22612 and related outpatient hospital services provided on February 11, 2021.  You asked the Plan to pay for the outpatient hospital services as billed. You say that this should be paid. The Plan denied your request. The Plan says this claim was billed with device dependent procedure code 22612 and does not report the device code.  The Plan must follow Medicare rules. Medicare rules say that outpatient hospital claims are passed through the I/OCE which applies edits to the claim. One such edit denies a claim with a device-dependent procedure when there is not a device also reported.  In this case, 22612 is a device-dependent procedure. No device code was reported on this claim as required. Therefore, we decided that the Plan does not have to pay for the outpatient lumbar fusion procedure coded as 22612 and related outpatient hospital services provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on December 30, 2020 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 office visit provided on December 30, 2020 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room (ER) services rendered on November 18, 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 99284 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 99284 (Level 4 ER visit) and 99285 (Level 5 ER visit). Code 99284 is a column II code with a modifier indicator of 1 when billed with column I code 99285. Code 99284 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 emergency room (ER) services rendered on November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from February 26, 2021, through March 6, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the member is covered for up to 100 days each benefit period for inpatient services in a SNF, in accordance with Medicare guidelines. A benefit period begins on the first day a member goes to a Medicare-covered inpatient hospital or a skilled nursing facility.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that the enrollee received 100 days of SNF care during the benefit period from November 17, 2020, through February 25, 2021. The Plan has covered 100 days of SNF care.   Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for SNF services provided from February 26, 2021, through March 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on May 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 services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on August 23, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that this was your first visit with this provider, and you do not understand how the visit exceeds that limitation. The Plan denied your request. The Plan says the service exceeds the frequency limitation to your benefit Plan.  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 a comprehensive oral evaluation once every three plan years.         We looked at the file and Medicare rules. The records show that you received a comprehensive evaluation on July 14, 2020, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on  August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit provided on September 10, 2020.
You asked the Plan to waive the deductible for the specialist office visit. You say that you were told the provider was in-network. 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. Your contract with the Plan says that there is $750 deductible which applies to each out-of-network Medicare-covered specialist office visit.
The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is $750 deductible which applies to each out-of-network Medicare-covered
specialist office visit. The record shows the provider was out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was
received on September 10, 2020. Therefore, we decided that the Plan does not have to waive the deductible for
the specialist office visit provided on September 10, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound (76642), provided on  July 30, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you should not have a cost share. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100 per day for diagnostic radiology services.      You have been asked to pay $100 for the ultrasound. This service 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 the ultrasound (76642), provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for diagnostic mammography, including CAD when performed (77065) provided September 2, 2021.  You asked the Plan to waive the copayment for the diagnostic service. You say that you went in for your routine mammogram. You don't know why it was billed as a diagnostic mammogram and was not routine. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $35 copayment for each basic imaging service.   You have been asked to pay $35 copayment for the diagnostic service. The diagnostic service 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 diagnostic mammography, including CAD when performed (77065) provided September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on August 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 the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that abortion services are generally not covered.   We looked at the file and Medicare rules. The file shows that the abortion services were not performed for a condition that is covered by Medicare. 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 surgical services rendered on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for eyeglasses provided on February 25, 2021.  You asked the Plan to reimburse you for the eyeglasses. You say that this provider is in-network, and you should be reimbursed. The Plan denied your request. The Plan says vision services are not covered out-of-network.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a Plan provider.  We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on  July 26, 2021.  You asked the Plan to waive the coinsurance for the injection. You say that the provider advised you that there would not be a copayment. 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 20% coinsurance for Part B drugs administered by a provider.      You have been asked to pay $291.93, which is 20% of the allowed amount for the injection ($1459.65 allowed amount x 20% coinsurance = $291.93). The 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 coinsurance for a denosumab injection provided on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on June 25, 2020, through June 30, 2020.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support a secondary diagnosis of cerebral edema.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis code G93.6. 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 inpatient hospital services. Our reviewer says that the documentation did not support the secondary diagnosis of cerebral edema. Our physician reviewer found review of the documentation received was incomplete to reflect evidence of member signs or symptoms attributed to cerebral edema or additional resource utilization during the encounter towards this condition such as IV steroids, continuous ICP monitoring,CSF drainage or intubation with hyperventilation. The initial and repeat CT head and MRI/MRA imaging would be consistent with management of an acute cerebellar bleed and not alone consistent with resource utilization supporting an additional diagnosis of cerebral edema. At the time of discharge, the member was diagnosed as having a cerebellar bleed without subsequent documentation of cerebral edema.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on June 25, 2020, through June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 28, 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 laboratory services provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services.  You asked the Plan to pre-approve physical therapy services. You say that the enrollee has made progress during the course of physical therapy. You say that the enrollee has difficulty with consistent transportation, which did limit attendance in the initial weeks of her scheduled appointments. You say that the enrollee's blood pressure regulation problems also contributed to her inability to complete a significant number of appointments in the initial approved time frame. You say that the records provided show the enrollee's improvements in strength, balance stability, and ambulation endurance and tolerance since her initial evaluation.    You say that the enrollee would benefit from ongoing skilled physical therapy intervention to further decrease her fall risk and potential for injury. The Plan denied your request. The Plan says the notes do not show that the criteria for coverage have been met.  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 pre-approve physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not support coverage for additional therapy visits. Additional physical therapy visits are not medically necessary just to improve the enrollee's endurance. Much of what the physical therapy is doing during therapy can be done by the enrollee with a home exercise program given to her.  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 pre-approve physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the transcutaneous electrical nerve stimulation (TENS) unit (E0730), provided on May 26, 2021.  You asked the Plan to waive the copayment for the TENS unit. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment (DME) and related supplies.   You have been asked to pay a 20% coinsurance for the TENS unit. This item falls within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the transcutaneous electrical nerve stimulation (TENS) unit (E0730), provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the definitive drug testing provided on June 11, 2021.  You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says this was not reported with the correct POS code.  The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.   We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluoroscopic guidance provided on April 14, 2021, billed with code 77003-59.  You asked the Plan to pay for the fluoroscopic guidance as billed. You say that this is a separate and distinct service performed to locate the spinal cord stimulator leads. This was correctly billed to modifier -59 to allow for payment. The Plan denied your request. The Plan says this code was not billed with an appropriate primary code. The Plan must follow Medicare rules. Medicare rules say that Type I add-on codes are only payable when billed with a specific set of primary codes.  CPT code 77003 is a Type I add-on code. The add-on code file indicates that the appropriate primary codes for 77003 are 61050, 61055, 62267, 62270, 62272, 62273, 62280, 62281, 62282, 62284, 64510, 64517, 64520, and 64610. None of these codes were billed on the claim. As such, this code does not meet Medicare rules for payment. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance provided on April 14, 2021, billed with code 77003-59.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 14, 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 services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 14, 2021.