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

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck you had on June 15, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not informed of this copayment and you feel it is too much compared to what you pay in your monthly premiums. The Plan denied your request. The Plan says you were charged this copayment 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 $100 copayment for diagnostic radiology services (including ultrasounds).
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the diagnostic radiology 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 ultrasound of the head and neck you had on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Venography (75825, 75882) and injection services (36005) provided March 8, 2021.
You asked the Plan to pay for Venography and injection services. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says these services are not separately covered.
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 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 Venography and injection services. Our reviewer says that the Venography and injection services are not supported by the medical records provided. Our reviewer found code 37248 includes all imaging and radiological supervision and interpretation, therefore billing codes 75882 and 75825 separately is considered unbundling and would not be covered. Code 36005 is inclusive to code 37248 and should not be reported separately.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Venography and injection services have not been met. Therefore, we decided that the Plan does not have to pay for Venography (75825, 75882) and injection services (36005) provided March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 11, 2021.
You asked the Plan to pay for services from this provider. You say that in your appeal to the Plan and in a letter sent directly to this office that your appeals are not being read and/or understood and you believe the Plan is required to cover these services. The Plan denied your request. The Plan says the Medicare data base shows this provided opted out of Medicare on July 1, 2016.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopy (up to one hour) provided on March 15, 2021, billed with code 76000.
You asked the Plan to pay for the services as billed. You say that this is separately payable. The Plan denied your request. The Plan says this is bundled with payment for code 49450 since there is no modifier used.
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 76000 is Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time.
We find that CPT code 76000 is not supported in the medical record. Specifically, another physician provided a gastronomy tube replacement on this date of service. This procedure is coded as 49450 and defined as replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. Review of the imaging report shows that fluoroscopy was done for 3 seconds during this procedure. As the fluoroscopic guidance is included in the payment for code 49450, the physician billing 76000 cannot also be paid for the same service included in code 49450. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopy (up to one hour) provided on March 15, 2021, billed with code 76000.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on December 25, 2020.
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 due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first.
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 medical services provided to the enrollee on December 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies; 3-4 studies (95908) provided March 16, 2021.
You asked the Plan to pay for nerve conduction studies. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says code 95908-26 remains not supported.
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 95908-26 is not supported for separate payment. Specifically, the medical records did not include documentation of nerve conduction studies; 3-4 studies.
Based on this information, we decided that Medicare rules for coverage of nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies; 3-4 studies (95908) provided March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (36415, 82728, 83540, 84443, 85025) provided on May 7, 2021, to May 24, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that your services were due to Covid-19 and should be covered at 100%. The Plan denied your request. The Plan says the copayments you are being charged are correct.
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 $10 copayment per day, per provider for outpatient diagnostic tests and therapeutic services and supplies including laboratory services. You have been asked to pay a $10 copayment per day, per provider for laboratory services. The records show that you had laboratory testing done on two separate dates of service. The EOC confirms that $10 is the required copayment for each laboratory service. The Plan's internal guidelines for Covid-19 treatment confirms that diagnostic testing is not a treatment of Covid-19 and will apply to Plan benefits. 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 (36415, 82728, 83540, 84443, 85025) provided on May 7, 2021, to May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide purchased on November 24, 2020.
You asked the Plan to pay for a stair glide. You say that a stair glide was medically necessary for your use and safety. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 stair glide purchased on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit (99213) provided on March
3, 2021.
You asked the Plan to waive the deductible for an office visit. You say that this service was provided as a preoperative
visit for surgery relating to diagnosis. The Plan denied your request. The Plan says the deductible you
are being charged is correct.
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 a $1,000 deductible for covered medical services.
The service at issue is subject to the Plan deductible of $1,000. The record shows that at the time this claim was processed, $156.25 of the $1,000 deductible had been met. The allowed amount of the claim is $98.89, resulting in a deductible obligation of $98.89. The EOC confirms that the office visit took place twenty-three days prior to your surgery, therefore, this visit does not apply to a pre-operative visit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on March 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit (99213) provided on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on April 12, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you received an Explanation of Benefits that says you owe $0 for a CT scan, but now you are getting a bill for $250. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you had two CT scans on that day and they only charge a per-day copayment. That is why the claim for the other CT scan you had on that day says you owe $0 for the other CT scan.
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 diagnostic radiology services (including CT scans).
You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the diagnostic radiology 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 computed tomography (CT) scan of the chest you had on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 15, 2021, to May 20, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were kept in the hospital while waiting for surgery. You also say that you could have left home and returned when surgery was available instead of staying in the hospital for several days. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $175 copayment per day, for days 1 to 5 for inpatient hospital care.
You have been asked to pay a $175 copayment for inpatient hospital care. The records show that you were inpatient for five (5) days, resulting in a total cost share of $875 ($175 x 5 days = $875). The EOC confirms that $175 is the required copayment per day for this service. 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 inpatient hospital care provided on May 15, 2021, to May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on July 2, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 physician services provided on July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extremity study you received on February 1, 2021.
You asked the Plan to waive the copayment for the extremity study. You say that your wellness exams in the past have never included extremity studies. You said that you did not request this test and it was performed without your approval. You stated that you would like this copayment waived. The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for diagnostic procedures and tests (except for bone mass measurements, diagnostic colonoscopies, and diagnostic mammograms). You have been asked to pay a $50 copayment for the extremity study. The extremity study falls within the diagnostic procedures and tests benefit category. This copayment applies regardless of the reason why you had this service. 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 extremity study you received on February 1, 2021.
Your complaint about this test being performed without your approval 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a chiropractor (99202) provided on May 17, 2021.

You asked the Plan to pay for an office visit. You say that you had services with a chiropractor, and you are inquiring on why the claim was denied. The Plan denied your request. The Plan says the service is not covered by the Plan.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit with a chiropractor (99202) provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 26, 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 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 out of network physician services provided to the enrollee on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing for multiple pathogens by polymerase chain reaction (PCR) provided on February 18, 2021.
You asked the Plan to pay for the pathogen PCR testing. You say that this is payable. The Plan denied your request. The Plan says these services are not payable.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when it is ordered by the treating physician. In this case, the documentation contains an unsigned physician order just selecting "Nail PCR" as the request test. There is a list of pathogens to test for, but none were selected. The lab billed tests for 15 different pathogens, but the order is not sufficiently detailed to support the intent of the physician to test for this number of pathogens. As there is no valid order for the services being billed, we find denial of payment is supported. Therefore, we decided that the Plan does not have to pay for the genetic testing for multiple pathogens by polymerase chain reaction (PCR) provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on June 12, 2020.
You asked the Plan to pay for the drug testing. You say that this is medically necessary and should be paid. The Plan denied your request. The Plan says the incorrect POS code is used.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly.
We looked at the file and Medicare rules. The documentation does not show that the sample was taken directly
by the lab. As such, the reported POS code of 81 is not supported. Based on this information, we decided that
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not
have to pay for the presumptive and definitive drug testing services provided on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for a patient of extreme age (91000) provided on April 15, 2021.
You asked the Plan to pay for anesthesia for a patient of extreme age. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says no separate payment is made for this code. Therefore, coverage criteria are not met.
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 91000 has a status code "B" and cannot be paid as billed. A status code "B" or a Bundled code, meaning payment for covered services are always bundled into payment for other services not specified. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for a patient of extreme age (91000) provided on April 15, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (82465-AY and 83036-AY) provided on March 8, 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 that the services are not covered as 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. In this case, the Plan is denying payment for codes 82465 and 83036 due to the diagnosis code billed. The file shows that the provider submitted these codes with an AY modifier due to the services provided were not for the treatment of end-stage renal disease (ESRD). The Plan; however, has not provided any evidence that diagnosis code N17.9 is not payable when billed for codes with an AY modifier. Therefore, we decided that the Plan has to pay for the laboratory services (82465-AY and 83036-AY) provided on March 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.