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

We decided that the Plan does not have to waive the copayment for the ultraviolet light treatment received in a dermatologist's office on June 16, 2021.

You asked the Plan to waive the copayment for the dermatology services. You say that this copayment is unfair because the light treatment received is not done by the doctor, but by someone on his staff. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($20.84) is less than the copayment obligation, the enrollee is responsible for the full allowed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for provider and professional services received in a specialist's office.

The enrollee has been asked to pay a $40 copayment for the dermatology services. This copayment applies for all services received in a specialist's office, even if the enrollee does not physically see a doctor. 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 ultraviolet light treatment received in a dermatologist's office on June 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT code(s): 64493 and 64494).

You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan denied your request. The Plan says the notes do not show that the Plan received an assessment or imaging of your back that shows this area as the only possible source of your pain. The Plan states this injection is not medically necessary. The Plan states the submitted imaging results and discussion with provider demonstrate that the requested level should be L2 to L3. The Plan states they may approve the injection for L2 to L3 for MBB to be done for you, if requested.

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 injections. Our physician reviewer found the initial denial was made due to the fact that the prior authorization was requesting a re-injection and there were no past records of the requested levels being injected. The provider stated that he is requesting bilateral L2 to L3 only (last in June 2021 with 80 to 100% improvement). Submitted imaging results and discussion with provider demonstrate that the requested level should be L2 to L3. May approve the injection for L2 to L3 for MBB to be done under fluoroscopy for you. The criteria are not met to overturn the denial for the requested levels for bilateral L4-5 and bilateral L5-S1 for re-injection. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT code(s): 64493 and 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services and injection services provided on March 25, 2021.

You asked the Plan to pay for these services. You say that you did not know the provider was out of network. 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 and injection services provided on March 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray you had at an outpatient hospital facility on July 16, 2021.
You asked the Plan to waive the copayment for the chest x-ray. You say that you were not aware of the cost sharing difference between providers because you didn't have a benefits book. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($88.36) is less than your copayment obligation, you are responsible for the full allowed 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 $95 copayment for basic radiology services at an outpatient hospital. You have been asked to pay a $95 copayment for the chest x-ray. The chest x-ray falls within the basic radiology services at an outpatient hospital 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 chest x-ray you had at an outpatient hospital facility on July 16, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81350, 81355, and 81381) provided to the enrollee on March 30, 2021.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been 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. 

If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will e considered part of the same panel. A panel constitutes a single procedural service, so on CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular pathology testing (CPT code(s): 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81350, 81355, and 81381) provided to the enrollee on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a primary care physician on April 5, 2021.

You asked the Plan to waive the copayment for the primary care visit. You say that you were not informed that you were seeing a specialist that involved a copayment of $50. The Plan denied your request. The Plan says you are only being charged a $25 copayment, not $50. The Plan says that you have been 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 $25 copayment for services with a primary care provider.

You have been asked to pay a $25 copayment for the primary care visit. 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 office visit you had with a primary care physician on April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for gastrectomy, total; with Roux-en-Y reconstruction (CPT code 43621) and enterectomy, resection of small intestine; with enterostomy (CPT code 44125) provided to the enrollee on May 7, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 the services. Our reviewer found the records indicate that the enrollee underwent a procedure. The operative note stated that the proximal stomach was divided below the gastroesophageal junction. Therefore, a total gastrectomy was not performed. CPT code 43621 cannot be recommended. The operative note does not state that an enterectomy was performed. No intestine was removed. CPT code 44125 cannot be recommended. 

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 services have not been met.

Therefore, we decided that the Plan does not have to pay for gastrectomy, total; with Roux-en-Y reconstruction (CPT code 43621) and enterectomy, resection of small intestine; with enterostomy (CPT code 44125) provided to the enrollee on May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap; trunk (CPT code 15734) provided to the enrollee on March 3, 2021.

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 the services are not supported by the records.

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 the service. Our reviewer found the record indicates that the enrollee underwent a surgical procedure. The provided records state that a myofascial release was carried out beginning lateral to the left rectus muscle. The operative note does not describe release of the external oblique. A complete component separation was not performed. The elements of the coverage criteria are not satisfied.

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 service have not been met. Therefore, we decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap; trunk (CPT code 15734) provided to the enrollee on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for electrocardiogram services provided on February 19, 2021.
You asked the Plan to waive the copayment for electrocardiogram services. You say that you believe these services should be fully covered under your plan. 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 $30 copayment for non-radiological diagnostic services, including EKGs (electrocardiograms).
You have been asked to pay a total allowed amount of $22.08, which is less than the $30 copayment for non-radiological diagnostic services. Electrocardiogram services falls 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 electrocardiogram services provided on February 19, 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 October 23, 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 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 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 October 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery services you received on March 23, 2021.

You asked the Plan to waive the copayment for the outpatient surgery services. You say that this was a failed surgery, so you should not have to pay a copayment. 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 $300 copayment for outpatient surgery. 

You have been asked to pay a $300 copayment for the outpatient surgery services. This copayment applies regardless of the success of the procedure. 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 outpatient surgery services you received on March 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 21, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you do not believe you should have to pay this copayment because you were sent to the ER by your orthopedist. You said that the ER doctor didn't put a needle in your arm, they just gave you medication. 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 $110 copayment for emergency room visits.

You have been asked to pay a $110 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit or the extent of services you receive there. 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 (ER) visit you had on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters (CPT code 95870-TC-59) and short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs (CPT code 95938-TC-59) provided to the enrollee on April 15, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed by the provider.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Per the Medicare guidelines we are upholding the denial as the billed CPT code(s) 95938-TC-59 and 95870-TC-59 have a physician Fee Schedule PCTC indicator of 1 and the claim a POS of 21-inpatient hospital. The professional interpretation was furnished in the same payment locality from where the TC was furnished. We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier - 26 by the interpreting physician. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan would accept a submission of a corrected claim to consider services for payment. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters (CPT code 95870-TC-59) and short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs (CPT code 95938-TC-59) provided to the enrollee on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for coronary angioplasty provided on April 21, 2021.

You asked the Plan to waive the coinsurance for coronary angioplasty. You say that the procedure could not be completed because there were not enough supplies. You say you should not owe anything. The Plan denied your request. The Plan says you are being 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 15% coinsurance for surgery and other services provided at an outpatient hospital. 

You have been asked to pay $351.26, which is less than the 15% coinsurance for coronary angioplasty, because you met your maximum out-of-pocket limit. Coronary angioplasty falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The record shows that the services were received. 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 coronary angioplasty provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had on April 19, 2021.

You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you received an injection and do not believe any surgery was done. 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 outpatient surgery. 

You have been asked to pay a $100 copayment for the arthrocentesis procedure. The procedure you received is considered an outpatient surgery.

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 arthrocentesis procedure you had on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the medical eye exam, the ophthalmic diagnostic imaging, and ophthalmic ultrasound you had on March 16, 2021.

You asked the Plan to waive the copayments for the medical eye exam, the ophthalmic diagnostic imaging and ophthalmic ultrasound. You say that this was a routine eye exam, so there should be no copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that you were charged a specialist copayment for the medical eye exam. The Plan also says that for the diagnostic ophthalmic imaging and ophthalmic ultrasound, the allowed amounts for these services ($43.86 and $14.13) are less than your copayment obligation, so you are responsible for the full allowed amounts for these services.

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 $110 copayment for diagnostic radiology services and a $45 copayment for medical eye exams. 

You have been asked to pay a $45 copayment for the medical eye exam, and a $110 copayment for the ophthalmic diagnostic imaging and ophthalmic ultrasound. The medical records from this visit do not show this was a routine eye exam. The medical records indicate that you were evaluated for glaucoma and dry eye syndrome. These are medical conditions for which the medical eye exam copayment applies. In addition, both the ophthalmic diagnostic imaging and the ophthalmic ultrasound are diagnostic radiology services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the medical eye exam, the ophthalmic diagnostic imaging, and ophthalmic ultrasound you had on March 16, 2021.