Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99204) provided on September 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that per your lookup of authorization, you found that for an interventional radiology (IR) short visit - no authorization is required. You also say this is a separate identifiable billable service that was performed out of medical necessity to best treat your patient. The Plan denied your request. The Plan says the services in question were not regarding emergent or urgently needed care and a prior authorization request for out-of-network services was not received.  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 specialist office visit (99204) provided on September 2, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the electronic connection (E2311).  You asked the Plan to pre-approve the electronic connection. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  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 electronic connection. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items exceed the patient's medical need. The patient has 2 power options  on the approved wheelchair but the patient's upper extremity function with independence in eating supports that the patient can control any power options through their own switches.  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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the electronic connection (E2311).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (76700) provided September 29, 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 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 76700 shares a bundled relationship with code 93976. 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 (76700) provided September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a raised toilet seat (E0244) provided on October 21, 2021.  You asked the Plan to pay for a raised toilet seat. You say that the item at issue is a medical necessity for your condition. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature.  While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a raised toilet seat (E0244) provided on October 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical endoscopy rendered on March 24, 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 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 33508 (surgical endoscopy, including video-assisted harvest of vein(s) for coronary artery bypass procedure) and 33533 (coronary artery bypass, using arterial grafts). Code 33508 is a column II code with a modifier indicator of 1 when billed with column I code 33533. Code 33508 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 surgical endoscopy rendered on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a telehealth office visit (99204) provided on June 22, 2021  You asked the Plan to waive the copayment for the telehealth office visit. You say that the services are fraudulent. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $35 copayment for Physician/Practitioner Services, Including Doctor's Office Visits.    You have been asked to pay a $35 copayment for the telehealth office visit. The medical records provided confirm that these services were 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 a telehealth office visit (99204) provided on June 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for a methylprednisolone injection (64483, J1030) provided on June 15, 2021.  You asked the Plan to reduce the copayment for a methylprednisolone injection. You say that you did not have surgery nor were you in an operating room. You also say you should not be charged the copayment for surgery. The Plan denied your request. The Plan says you were 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 $300 copayment for each Medicare-covered outpatient surgery service.     You have been asked to pay a $300 copayment for a methylprednisolone injection. A methylprednisolone injection 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 reduce the copayment for a methylprednisolone injection (64483, J1030) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an influenza vaccine (flu shot) provided on October 6, 2021.  You asked the Plan to waive the coinsurance for the flu shot. You say that you did not know that the provider was out-of-network (OON). 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 50% coinsurance for each pneumonia, influenza, and Hepatitis B vaccine.      Item/Service Allowed Amount 50% Coinsurance Office Visit (99204) $162.42 $81.21 Influenza Vaccine (90662) $51.50 $25.75 Vaccine Administration (G0008) $16.36 $8.18 Total:  $115.14  You have been asked to pay $115.14, which is 50% of the allowed amount for the flu shot. The flu shot falls within the Immunizations 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 an influenza vaccine (flu shot) provided on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving overall and only requires short-term additional acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when the enrollee is more stable and when treatment is complete.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewings - two radiographic images (D0272), prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided September 22, 2021, by an OON provider.  You asked the Plan to pay for the bitewing x-rays, dental cleaning, and periodic oral exam. You say that the dental office told you they were in-network and the services would be covered. The Plan denied your request. The Plan says these services are not covered because they were provided OON.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the bitewing x-rays, dental cleaning, and periodic oral exam when the services are provided by a participating provider.  We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the bitewing x-rays, dental cleaning and periodic oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the bitewings - two radiographic images (D0272), prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided September 22, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the office visit services provided on September 8, 2021.  You asked the Plan to pay for the office visit services. You say that you would like the Plan to reconsider their denial of payment as you say you have never been denied for coverage of these services before and that you have been seeing the same primary care physician forever. The Plan denied your request. The Plan says that services required by a third party are not covered.  The Plan must follow Medicare rules. Medicare rules say that when a contracted provider furnishes a service or refers an enrollee for a service that an enrollee reasonably believes is a plan-covered service, the enrollee cannot be financially liable for more than the applicable cost-sharing for that service. In this case, the file does not show that you were provided notice that this office visit would not be covered. The file does show that you reasonably believed that this office visit would be covered.   The rules also 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. Specifically, there is no documentation in the case file to support the services were required by a third party.  Based on this information, we decided that Medicare rules for coverage of the office visit have been met, and you cannot be financially liable for more than the applicable cost-sharing for an office visit with your primary care physician. Therefore, we decided that the Plan has to pay for the office visit services provided on September 8, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), and electronic connection (E2311).  You asked the Plan to pre-approve the expandable controller, harness, and electronic connection. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  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 expandable controller, harness, and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not require non-proportional input devices, a separate display, other electronic devices, or an attendant control.  The patient has 3 power options of tilt, recline, and power elevating leg rests but the patient does not need to control the power options through a joystick. The patient's left upper extremity strength and function support that the patient can control any power options through their own switches.  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 expandable controller, harness, and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), and electronic connection (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had a complicated and prolonged hospital course and appears to be ventilator dependent. The record indicates that the enrollee requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.   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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the thorax, with dye, provided on August 2, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you cannot afford the copayment, and the provider advised you that there would only be a $35 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 $160 copayment for each radiological diagnostic service, not including X-rays.   You have been asked to pay a $160 copayment for the CT scan. CT scans 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 a computed tomography (CT) scan of the thorax, with dye, provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided June 2, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided June 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an EGD.  You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says the documentation fails to indicate that the member has had a colonoscopy that was negative for blood loss. Therefore, the Medicare medical necessity criteria are not met as per Local Coverage Determination (LCD), Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350).  The Plan follows Medicare rules. Medicare rules say that Endoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present.  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 an EGD. Our reviewer says that an EGD is not medically necessary. Our physician reviewer found that the available record neither supports evidence of GI blood loss nor of recent colonoscopy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have to pre-approve an EGD.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 18, 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 June 18, 2021.