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

 We decided that the Plan does not have to waive the copayment for a bone marrow aspiration and biopsy provided on July 20, 2021.  You asked the Plan to waive the copayment for the bone marrow aspiration and biopsy. You say that you feel you should not have to pay the copayment since the sample was no good. 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 $250 copayment for outpatient surgery.   You have been asked to pay a $250 copayment for the bone marrow aspiration and biopsy. The bone marrow aspiration and biopsy 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 bone marrow aspiration and biopsy provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.    We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the back brace (L0650) provided on August 24, 2020.  

You asked the Plan to pay for the back brace. You say that you would like reconsideration because the documentation supports the service billed. The Plan denied your request. The Plan says the documentation does not support this equipment.  

The Plan follows Medicare rules. Medicare rules say that if a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.  

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 back brace. Our reviewer says that the member does not meet LCD criteria for coverage of the back brace. Our physician reviewer found the provided office visit note makes no mention of a need for or an order for a back brace to reduce pain by restricting mobility of the trunk; or to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a deformed spine.  

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 back brace have not been met. Therefore, we decided that the Plan does not have to pay for the back brace (L0650) provided on August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for initial hospital services (procedure code 99222) provided to the enrollee on February 7, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider reported multiple evaluation and management services on the same date of service which does not follow industry standard coding rules.  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 99222 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the provider was paid for CPT 99222 under claim #11361454 for date of service February 7, 2021. The documentation supports one evaluation and management service was provided on February 7, 2021 at 13:35. Any additional payment for this service would not be covered, and be considered duplicate billing.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital services (procedure code 99222) provided to the enrollee on February 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuromonitoring services provided on February 11, 2021.  You asked the Plan to pay for the neuromonitoring services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.  We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency saphenous vein ablation.  You asked the Plan to pre-approve radiofrequency saphenous vein ablation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 radiofrequency saphenous vein ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee records do not clearly show the enrollee without a current deep vein thrombosis (DVT) to help support the safe completion and appropriateness of this procedure. Therefore, the radiofrequency venous ablation procedure will be considered not medically necessary based on the provided documentation.      We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency saphenous vein ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency saphenous vein ablation.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravenous infusion (96365), provided on September 22, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the intravenous infusion. You say that the service was medically necesary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services provided by an out-of-network 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. 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 intravenous infusion (96365), provided on September 22, 2021 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 (81292, 81321, 81405, 81406, 81408, 81201, 81163, 81164, 81293, and 88237) provided on June 18, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (81292, 81321, 81405, 81406, 81408, 81201, 81163, 81164, 81293, and 88237) provided on June 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography guidance for placement of radiation therapy fields (77014) provided July 6, 2021.  

You asked the Plan to pay for the diagnostic service. You say that please review and reprocess claim with notes. The Plan denied your request. The Plan says 77014 should not be reported in addition to procedure 77301. 77014 is used for the planning for intensity-modulated radiation therapy and is a component of procedure 77301. 

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, we have confirmed that code the diagnostic service is a column II code to column I code 77301. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography guidance for placement of radiation therapy fields (77014) provided July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an intraoral periapical additional radiographic image (D0230) provided on August 23, 2021.  You asked the Plan to pay for an intraoral periapical additional radiographic image. You say that this was your first visit with this provider and the dental hygienist had no x-rays on file. You also say these x-rays were needed and done at the initial visit and should be covered. The Plan denied your request. The Plan says the one periapical x-ray was denied for exceeding the frequency limitation under your dental 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 4 intraoral periapical radiographic images in a 12-month period.        We looked at the file and Medicare rules. The records show you received three periapical x-rays on June 29, 2021. The records also show you received two periapical x-rays on August 23, 2021 and one of the x-rays were covered. The EOC confirms you receive 4 periapical x-rays in a 12-month period. As of this date of service you exhausted your maximum allowed benefit for this service, therefore, the remaining x-ray is not a covered benefit with your Plan. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical additional radiographic image have not been met. Therefore, we decided that the Plan does not have to pay for an intraoral periapical additional radiographic image (D0230) provided on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging (78452) provided on June 25, 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 service 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 $0 copayment for mammography and ultrasounds. Additionally, you must pay a $95 copayment for all other diagnostic and nuclear medicine radiological services.  

You have been asked to pay a $95 copayment for the diagnostic radiological service provided. 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 myocardial perfusion imaging (78452) provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from August 19, 2021, to August 24, 2021.  You asked the Plan to waive the copayment for the inpatient care. You say that you should not be responsible for this copayment because this hospital care was related to COVID-19 and was not your fault. The Plan denied your request. The Plan says Medicare covers all necessary hospitalizations. This includes if you are diagnosed with COVID-19 and might otherwise have been discharged from the hospital after an inpatient stay, but instead you need to stay in the hospital under quarantine. You still pay for any hospital deductibles, copays, or coinsurance that apply. Your contract with the Plan states that you are responsible for a $393 copayment for each of the first five days of an inpatient hospital stay. This claim was processed 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 $393 copayment for each of the first five days of an inpatient stay.   You have been asked to pay a $1,965 copayment for the five-day inpatient stay ($393 x 5 days = $1,965). 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 inpatient hospital admission and services provided from August 19, 2021, to August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on September 16, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  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 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 out of network medical services provided to the enrollee on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the breast prosthesis brassier provided on June 22, 2021.  

You asked the Plan to waive the coinsurance for the breast prosthesis brassier. You say that there should not be 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 a 20% coinsurance for prosthetic devices and related supplies.   

You have been asked to pay a 20% coinsurance for the breast prosthesis brassier. This item falls within the prosthetic devices 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 coinsurance for the breast prosthesis brassier provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (80053, 87086, 87186, 87077, and 81001) provided on March 29, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.    The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (80053, 87086, 87186, 87077, and 81001) provided on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided August 18, 2021.  

You asked the Plan to waive the copayment for the emergency ambulance services. You say that the cost of the service is a financial burden and if you had just Medicare coverage you believe you would have a lower cost. The Plan denied your request. The Plan says the copayment 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 $200 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  

You have been asked to pay a $200 copayment for the emergency ambulance services. The emergency ambulance services fall within the Ambulance 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 waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the cataract surgeries (66984 x 2) provided on June 4, 2021 and June 18, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have 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 $195 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay $390 ($195 copayment x 2) for the Medicare-covered surgeries provided at an ambulatory surgical center. 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 the cataract surgeries (66984 x 2) provided on June 4, 2021 and June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid (87798) provided on July 21, 2021.  You asked the Plan to pay for code 87798. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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 CPT Code Manual definition of code 87798 is Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.  We find that CPT code  is not supported in the medical record. Specifically, this service was billed with modifier 91. This modifier may not be used when tests are rerun to confirm initial results, or due to testing problems with specimens or equipment. Modifier 91 may only be used for laboratory test(s) performed more than once on the same date on the same enrollee. Review of the documentation does not support the correct billing of modifier 91 for these services. Based on this information, we decided that Medicare rules for coverage of code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for the Infectious agent detection by nucleic acid (87798) provided on July 21, 2021.