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

We decided that the Plan does not have to waive the copayments for the physician services, the ambulance services, and the emergency care services provided from March 16, 2020 to February 17, 2021.

You asked the Plan to waive the copayments for the services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the correct copayments have applied for these services per your contract with the Plan.

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 for primary care visits, a $30 copayment for specialist services, a $100 copayment for Emergency care services, and an $80 copayment for Ambulance services. 

We looked at the file, the Plan's contract and Medicare rules. In this case, the file shows that you received an office visit on March 16, 2020. You have been asked to pay a $20 copayment for the office visit. The file shows that you also received an office visit on January 19, 2021 and were asked to pay a $5 copayment, which is less than the contracted $20 copayment amount. The file shows that you also received an office visit on February 16, 2021 and you were asked to pay a $20 copayment. The file shows you received a specialist visit on February 17, 2021 and you were asked to pay a $30 copayment. These office visits and specialist services fall within the Physician/Practitioner services benefit category. 

The file also shows that you received emergency care on February 12, 2021. You have been asked to pay a $100 copayment for the emergency care. The emergency care falls within the Emergency care benefit category. 

The file also shows that you received ambulance services on February 12, 2021. You have been asked to pay an $80 copayment for the ambulance services. The ambulance services fall within the Ambulance services benefit category. 

This means that you have been asked to pay the correct amounts 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 physician services, the ambulance services, and the emergency care services provided from March 16, 2020 to February 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on January 20, 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 99285 is 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.

In this case, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity. 

We find that CPT code 99285 is not supported in the medical record. Specifically, the records do not support the Level 5 intensity of care. 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 emergency room (ER) services rendered on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator (E1390) provided on April 8, 2021.

You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received durable medical equipment on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 19% coinsurance for Durable medical equipment. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an oxygen concentrator on April 8, 2021. You have been asked to pay a 19% coinsurance for the oxygen concentrator, totaling $20.82. The oxygen concentrator falls within the Durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen concentrator (E1390) provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided December 31, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that the device was medically necessary. The Plan denied your request. The Plan says this device is non-covered.

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. 

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. This item is used for a preventative service and is excluded from Medicare coverage.

The device was used in a facility and is not eligible for separate payment. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a 
pneumatic appliance (E0673). 
 
You asked the Plan to pay for an intermittent limb compression device and a pneumatic appliance. You say that 
the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says 
pneumatic compression devices are not covered by Medicare for deep vein thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression 
device (E0675) and a pneumatic appliance (E0673).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from November 16, 2020 to December 1, 2020.

You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that the home health services billed were provided to the enrollee, as there were no records for the billed November 16, 2020 to December 1, 2020 dates of service. Therefore, we decided that the Plan does not have to pay for the home health services provided from November 16, 2020 to December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0223U) provided January 27, 2021.

You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. The testing at issue was for 6 or more pathogens. 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 (0223U) provided January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, toe(s), minimum of 2 views (73660) provided October 26, 2020.

You asked the Plan to pay for the diagnostic services. You say that please reconsidered payment. The x-ray of your little the on your right foot which turned out to be broken and was determined by this x-ray. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

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 the radiologic examination, toe(s), minimum of 2 views (73660) provided October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior instrumentation coded as 22846 provided February 9, 2021.

You asked the Plan to pay for the anterior instrumentation. You say that the medical records submitted support the service as billed. The Plan denied your request. The Plan says the medical records do not support the billed code 22846.

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 22846 is Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure). 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the anterior instrumentation. Our reviewer says that the documentation provided does not support the code as billed. Our reviewer found the use of the requested code requires the device to be able to be used in a standalone fashion without other devices. In this case, the record indicates that anterior placement of interbody spacers and buttress plates were placed at the L3-L4, L4-L5, and
L5-S1 levels. A buttress place is not a standalone device. The elements of the coverage rule are not satisfied. The medical records do not support the services as billed. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anterior instrumentation have not been met. Therefore, we decided that the Plan does not have to pay for the anterior instrumentation coded as 22846 provided February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the hydration therapy rendered on May 12, 2020. 
 
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 that the services are not covered. 
 
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 states that the services were rendered in the state of New Jersey and 
that Local Coverage Determination (LCD) L34960 is binding; however, there is no documentation in the file to 
support that the services were rendered in New Jersey. The claim dispute form lists a National Provider 
Identifier (NPI) number that is listed as located in New York. The Plan has not provided any further 
documentation or rules to support that the services are not payable. Therefore, we decided that the Plan has to 
pay for the hydration therapy rendered on May 12, 2020.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 5, 2021.

You asked the Plan to pay for drug testing. You say that physicians send specimens to your lab for testing and
you do not have any access to physician notes and reports. The Plan denied your request. The Plan says the
denial of payment for this testing is correct, because the documentation submitted does not support the Place of
Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken
in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for
this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not
been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 5,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82947) provided January 8, 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 procedure code billed shares a bundled relationship with another billed code and cannot be paid.

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 82947 has a Column One/Column Two relationship with code 82945 and cannot be paid as billed. 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 lab services (82947) provided January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for application to 1 or more areas for, but not limited to, hot or cold packs (97010) and electrical stimulation (unattended) (G0283) provided April 29, 2021 to May 18, 2021
.
You asked the Plan to pay for the chiropractic services. You say that the Plan has denied your chiropractic care for no reason. The chiropractor had been treating you for your back pain and the treatment is the only thing that relieves your pain. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor

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 application to 1 or more areas for, but not limited to, hot or cold packs (97010) and electrical stimulation (unattended) (G0283) provided April 29, 2021 to May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for hydration therapy (96360) provided May 7, 2020. 
 
You asked the Plan to pay for the hydration therapy. You say that the services were medically necessary. The 
plan did not apply the correct Local Coverage Determination. The Plan denied your request. The Plan says that 
the service was not billed correctly under Medicare rules. 
 
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 documentation and denial letter provided by the plan does not detail how the 
provider failed to correctly bill this service. The plan did not articulate how the CPT code billed did not meet 
the requirements of the cited Local Coverage Determination. Therefore, we decided that the Plan has to pay for 
hydration therapy (96360) provided May 7, 2020.  
 
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 intraoperative neuromonitoring services provided on
January 18, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
codes cannot be verified.

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 95955 is electroencephalogram (EEG) during non-intracranial surgery (eg, carotid surgery). We find that this code is not supported in the medical record. There is a more comprehensive code available to describe the services provided.

The CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited. The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95927 is short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. We find that the CPT codes are not supported in the medical record. Specifically, the documentation did not indicate the billed codes were provided. There are more comprehensive codes to describe the services.

The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that Train of Four testing does not fit the criteria set by CMS and Insurance Carriers for CPT code 95937. There is no separate code for Train of Four Monitoring, therefore, it would be inappropriate to bill the Neuromuscular Junction Testing code for Train of Four Monitoring.
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 intraoperative neuromonitoring services provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement provided on February 19, 
2021. 
 
You asked the Plan to waive the copayment for these services. You say that you are being charged for services 
not provided. The Plan denied your request. The Plan says that the correct procedure codes were billed for the 
services you received. 
 
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 Medicare-covered outpatient surgery visit to an outpatient hospital or an ambulatory 
surgical center.  
 
You have been asked to pay a $159.20 copayment for these services. These services fall within the Medicare-
covered outpatient surgery visit to an outpatient hospital or an ambulatory surgical center benefit category. This 
means that you have been asked to pay less than 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 debridement provided on February 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit services provided on
March 3, 2021.

You asked the Plan to waive the copayment for the specialist visit services. You say that you feel the enrollee
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says the enrollee received services provided by a specialist on the date
of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's
contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $30 copayment for each Medicare-covered specialist visit or telehealth service with a specialist.

We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received services provided by a specialist on March 3, 2021. The enrollee has been asked to pay a $30 copayment for the specialist visit services. The specialist visit services fall within the Physician/Practitioner services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist visit services provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes (A5500, A5512) provided March 3, 2021. 
 
You asked the Plan to pay for the diabetic shoes. You say that the diabetic shoes should be covered. The Plan 
denied your request. The Plan says the deductible was not met at the time the shoes were provided. 
 
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 $750 deductible which applies to all covered services.  
 
The deductible applies to the diabetic shoes. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $750 deductible which applies to all covered services. This cost sharing is a contractual 
obligation that had not been met at the time the diabetic shoes was received on March 3, 2021. $329.18 was 
applied to the $750 deductible. Therefore, we decided that the Plan does not have to pay for diabetic shoes 
(A5500, A5512) provided March 3, 2021.