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

We decided that the Plan does not have to pay for the magnetic resonance angiography coded 70544 provided 
on August 19, 2021.

You asked the Plan to pay for the magnetic resonance angiography. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 
for the magnetic resonance angiography 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 the magnetic resonance 
angiography coded 70544 provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 10, 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 10, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 8, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the 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 $90 copayment for each Medicare-covered visit.    You have been asked to pay a $90 copayment for the emergency room visit. the emergency room visit falls within the "Emergency care" 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 emergency room visit provided on September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on September 9, 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 70544 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 70544 (MRA of the head) and 70551 (magnetic resonance imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 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 magnetic resonance angiography (MRA) of the head rendered on September 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 29, 2021.

You asked the Plan to waive the copayment for the emergency ambulance services. You say that you believed that if you were admitted to the hospital, the ambulance copayment would be waived. The Plan denied your request. The Plan says the copayment was applied correctly. You benefits do not waive ambulance copayments when admitted to the hospital.

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 each one-way Medicare-covered ground trip by ambulance. 

You have been asked to pay a $250 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, advanced life support, emergency transport, level 1 (A0427) provided June 29, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing (CPT code G0482) provided to the enrollee on February 1, 2021.
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says that the service is not supported. The Plan states the submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service (POS) 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. he Plan's denial is not substantiated. The Plan paid for another drug test that was billed with the same place of service as CPT code G0482. Therefore, the Plan has to pay for this test. Based on this information, we decided that Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay for the drug testing (CPT code G0482) provided to the enrollee on February 1, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the chest (71250) provided on September 1, 2021.

You asked the Plan to waive the copayment for a CT scan of the chest. You say that the service at issue was related to your Coronavirus treatment and that the Plan has waived all copayments for Coronavirus treatment. The Plan denied your request. The Plan says the correct copayment 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 $275 copayment for advanced imaging services at an outpatient hospital. 

In this case, the provided medical records do not document that the service at issue was related to Coronavirus treatment. You have been asked to pay $104.60 for a CT scan of the chest. A CT scan of the chest falls 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 copayment for a CT scan of the chest (71250) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 11,
2021.

You asked the Plan to waive the copayment for the laboratory services. You say that you feel that you should
not be responsible for the copayment. 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 $20
copayment per visit for laboratory tests.

You have been asked to pay $16.55, which is less than the $20 copayment for the laboratory services.
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 copayment for laboratory services provided on May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for reprogramming of programmable
cerebrospinal shunt (CPT code 62252) provided on August 6, 2021, by the outpatient department of the
hospital.

You asked the Plan to waive the copayment for the service. You say that you had previous shunt adjustments
and were never billed. You state that the services were performed at a public waiting room and not a treatment
room. The Plan denied your request. The Plan says they reviewed your claim history and verified that previous
shunts adjustments were performed at a physician's office. The Plan states the copayment for service rendered
on date of service August 6, 2021, is being assessed correctly per your plan benefits and how the provider
coded the claims submission.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).

Review of the file shows that reprogramming of programmable cerebrospinal shunt (CPT code 62252) on
August 6, 2021, by the outpatient department of the hospital. The Medicare-allowed amount for the outpatient
services is less than the set $295 copayment; therefore, you have been asked to pay the lesser amount of
$259.87 for the outpatient services. Your 2021 EOC states that enrollees must pay a $295 copayment for
Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited
to hospital or other facility charges and physician or surgical charges. 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 reprogramming of programmable cerebrospinal shunt (CPT code 62252) provided on August 6,
2021, by the outpatient department of the hospital.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided to the enrollee
on September 9, 2021, by out-of-network providers.

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your
request. The Plan says this provider is out-of-network, the services were not referred by a network provider,
and the 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 the drug testing (CPT code G0480) provided to the
enrollee on September 9, 2021, by out-of-network providers.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80048, 80076, 87340, 
85025,36415, 84460, 82247, 82172, 83883, 82977, 83010, 86706, G0475, 86790, 86704, 85610, 87902, 87522, 
87521, and G0463) provided on March 15, 2019, by an out-of-network provider.

You asked the Plan to pay for the out-of-network laboratory services. You say that the Plan paid for all charges 
except the laboratory services. The Plan denied your request. The Plan says this provider is out-of-network, the 
services were not referred by a network provider, and the services were not urgent or emergent, nor were they 
approved in advance. The Plan states that you received a One-Time Exception for date of service March 5, 
2019 with an out-of-network provider because your plan does not have out-of-network benefits.

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 (CPT code(s): 80048, 
80076, 87340, 85025,36415, 84460, 82247, 82172, 83883, 82977, 83010, 86706, G0475, 86790, 86704, 85610, 
87902, 87522, 87521, and G0463) provided on March 15, 2019, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 14, 2020 by a non-participating 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 a non-participating 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 August 14, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on March 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that you were unaware that the laboratory work needed prior authorization. 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 laboratory work provided on March 9, 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 brachytherapy source, non-stranded, yttrium-90, per source (CPT code C2616) provided to the enrollee on July 9, 2021, by out-of-network providers.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the 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 the brachytherapy source, non-stranded, yttrium-90, per source (CPT code C2616) provided to the enrollee on July 9, 2021, by out-of-network providers.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 81455)
provided to the enrollee on June 15, 2021.

You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied
your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory service have not been met. Targeted genomic
sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and
will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to
pay for targeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 
87851, 87634, 87640, 87798) provided April 15, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.

We find that CPT code 87486, 87496, 87498, 87502, 87532, 87541, 87851, 87634, 87640, & 87798 is not 
supported in the medical record. Specifically, the place of service listed on the claim form (11, office setting) 
does not match the place of service detailed in the records (13, assisted living facility). Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87851, 
87634, 87640, 87798) provided April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen and oxygen supplies, life sustaining situation
(A0422) provided on May 22, 2021.
You asked the Plan to pay for oxygen and oxygen supplies, life sustaining situation (A0422). The Plan denied
your request. The Plan says suppliers are paid at a base rate to include supplies with milage allowed separately.
The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen,
is included in the fee schedule payment.
We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen,
is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for oxygen
and oxygen supplies, life sustaining situation (A0422) provided on May 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for an injection of triamcinolone acetonide (J3304)
rendered on January 13, 2021. We have also decided that the Plan has to waive the deductible applied to an
office visit (99212) and the deductible applied to an arthrocentesis (20610) also rendered on January 13, 2021.
You asked the Plan to waive the coinsurance for an injection of triamcinolone acetonide. You also asked the
Plan to waive the deductible applied to an office visit and the deductible applied to an arthrocentesis. You say
that you only had an injection that day of service and no other services. The Plan denied your request. The Plan
says that you were charged the correct cost sharing amount.
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 provided an explanation of benefits (EOB) nor have they
provided a full Evidence of Coverage (EOC). The one page of the EOC that the Plan sent to us indicates a
range of coinsurance with no information about when what percentage applies for the Medicare Part B Drugs.
There is also no information about any deductibles in the one page of the EOC that was sent to us. Therefore,
we decided that the Plan has to waive the coinsurance for an injection of triamcinolone acetonide (J3304)
rendered on January 13, 2021. We also decided that the Plan has to waive the deductible applied to the office
visit and the deductible applied to the arthrocentesis also provided on January 13, 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