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

 We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on July 5, 2021.  You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  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 70450 is a column II code to column I code 70496. 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 a computed tomography scan (70450) provided on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on September 14, 2021.  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 office visit (99203) rendered by the out-of-network (OON) provider on  September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (71045) provided August 26, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is not separately payable.  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 71045 shares a bundled relationship with code 71046. 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 radiology services (71045) provided August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the duplex scan provided on July 23, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not 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.  The file shows that CPT code 93880 was billed with code 76536. We looked at the file and the rules. We find that CPT code 93880 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an outpatient hospital clinic visit provided on September 24, 2021, by an OON provider.  You asked the Plan to pay for an outpatient hospital clinic visit. You say that the enrollee was in ongoing treatment for this condition and was already scheduled for this service. The Plan denied your request. The Plan says enrollees must see in-network providers.   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 an outpatient hospital clinic visit provided on September 24, 2021, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on June 10, 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 there is no valid physician order.  The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any durable medical equipment (DME) item to a beneficiary.  We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor (CGM) supplies rendered on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 4, 2021.  You asked the Plan to pay for the limited exam. You say that this service was necessary, and you feel the provider barely performed any exam at all. The Plan denied your request. The Plan says limited oral exams to evaluate a problem can only be covered once per year. You had a previous limited evaluation on September 28, 2021, which was covered by the Plan at that time. Therefore, the exam provided on the date in question exceeded the limitations of your benefit.  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 can cover one limited exam to evaluate a problem (D0140) per plan year. Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam in requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the Plan has covered a previous limited exam for you in September 2021. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) and an influenza virus vaccine (90662, G0008) provided on September 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit (99336) and an influenza virus vaccine. You say that both the facility and the doctor are contracted with the Plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that they have also determined that these services were not urgent or emergent, nor were they approved in advance.  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 a domiciliary or rest home visit (99336) and an influenza virus vaccine (90662, G0008) provided on September 29, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for MRI scans of the pelvis (72197, 72195) provided on June 16 and June 18, 2021.  You asked the Plan to waive the copayments for MRI scans of the pelvis. You say that the second MRI was needed as the first did not have a clear enough image and that the provider advised you that you would not be responsible for a second copayment. The Plan denied your request. The Plan says the correct copayments were 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 $300 copayment for each visit for all other outpatient diagnostic and therapeutic services and supplies.   You have been asked to pay a $300 copayment for an MRI scan of the pelvis provided on June 16, 2021, and $293.74 for an MRI scan of the pelvis provided on June 18, 2021. MRI scans of the pelvis fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to the full and 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 MRI scans of the pelvis (72197, 72195) provided on June 16 and June 18, 2021.   Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from a representative of the provider 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.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an X-ray of the chest provided on June 11, 2021.  You asked the Plan to waive the deductible for the X-ray. You say that you feel that you should be responsible for a 20% coinsurance since your deductible was met. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  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 $500 deductible which applies to certain items and services.   The X-ray you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the time the X-ray was received on June 11, 2021. Please note that this deductible is applied on the date of service, not the billing date. Therefore, we decided that the Plan does not have to waive the deductible for an X-ray of the chest provided on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on April 22, 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 were not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 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 cardiovascular risk assessment panel, 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 February 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the POEM procedure.  You asked the Plan to pre-approve the POEM procedure. The Plan denied your request. The Plan says the POEM procedure is not covered due to the lack of evidence in the peer-reviewed, published literature to support the long-term safety and efficacy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the POEM procedure. Our reviewer says that the requested POEM procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that in Yang et al (1) retrospective series of 11 patients with an esophageal diverticulum (Zenker's 7, mid-esophagus 1, epiphrenic 3) the mean size of the esophageal diverticula was 34.5 mm, the overall technical success rate of D-POEM was 90.9 %, with a mean procedure time of 63.2 minutes. There were no adverse events, with a decrease in mean dysphagia score from 2.7 to 0.1 (P < 0.001) during a median follow-up of 145 days (interquartile range 126 - 273).  CONCLUSIONS: "the procedure is feasible, safe, and effective in the management of esophageal diverticula [but] larger studies are needed."  While promising, the technique is experimental, not standard of care, and as such does not meet coverage criteria outside of an investigational setting.  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 POEM procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the POEM procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Entresto.  You asked the Plan to pre-approve Entresto. You say that the service is medically necessary. The Plan denied your request. The Plan says Entresto is a self-administered drug.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Entresto.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on May 30, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 30, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on October 26, 2020, through November 4, 2020 and billed with Patient Driven Payment Model (PDPM) codes IAID1 x 6 days & IAID1 x 3 days.  You asked the Plan to pay for the SNF services billed with PDPM codes IAID1 x 6 days & IAID1 x 3 days. You say that you would like reconsideration because the documentation submitted supports the PDPM codes that were billed. The Plan denied your request. The Plan says that the documentation does not support the PDPM codes that were billed.  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 Plan has not forwarded sufficient information to substantiate their denial. There is no indication as to what specific aspects of section GG affect the coding of the billed PDPM code. Additionally, the documentation submitted outside of the  Assessment Reference Date (ARD) clearly reflects the member's functional status upon admission. It is appropriate to use this documentation when reviewing the PDPM code. It is the burden of the Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on October 26, 2020, through November 4, 2020 and billed with Patient Driven Payment Model (PDPM) codes IAID1 x 6 days & IAID1 x 3 days.   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound provided on September 22, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We looked at the file and the rules. The records show that CPT code 76705 was billed with code 93976. We find that CPT code 76705 may be eligible for payment when billed with this code pair. The claim provided for the billed services does not show that code 76705 was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound provided on September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography (70544) provided on September 7, 2021.  You asked the Plan to pay for magnetic resonance angiography. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  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 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography (70544) provided on September 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound care services provided on August 19, 2021.  You asked the Plan to pay for wound care. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the enrollee had elected hospice which was in effect on the date the services at issue were rendered.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on August 17, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for wound care services provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for clinic visits and arthrocentesis provided by Ochsner LSU Health Shreveport from January 7, 2021, to August 12, 2021.   You asked the Plan to waive the copayments for the clinic visits and arthrocentesis. You say that you were charged for minor surgery on these dates, and you had injections. 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 $300 copayment for surgery services at an in-network outpatient hospital.    You have been asked to pay a $300 copayment for the clinic visits and arthrocentesis for each date of service. The clinic visits and arthrocentesis fall within the "Outpatient hospital services" benefit category. The record shows the arthrocentesis are considered surgical procedures. 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 clinic visits and arthrocentesis provided from January 7, 2021, to August 12, 2021.