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

We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on July 20, 2021, billed
with code 76705-26.

You asked the Plan to pay for the ultrasound interpretation as billed. You say that these should be paid as multiple exams were
provided on the date of service. The Plan denied your request. The Plan says this was not billed with an appropriate modifier.

The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only the Column 1 code is payable unless a clinically appropriate modifier is used.

Code 76705 is a Column 2 code in relation to code 93976 which was also billed for this date of service. No clinically appropriate
modifier was used to justify bypassing this edit. Based on this information, we decided that Medicare rules for coverage of the
ultrasound interpretation as billed have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on July 20, 2021, billed with code 76705-26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the outpatient hospital clinic visit (G0463) provided on June 17, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $300 copay for each Medicare-covered outpatient hospital facility visit. You have been asked to pay $112.88 for the Medicare-covered outpatient hospital facility visit provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment.
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 adjust the copayment for the outpatient hospital clinic visit (G0463) provided on
June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dehumidification of hearing aids (V5299) and sales tax (S9999) provided on June 15, 2021.
You asked the Plan to pay for dehumidification of hearing aids and sales tax. You say that the requested service is a necessity to prevent malfunction and infection. The Plan denied your request. The Plan says rules for hearing services have not been met.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to a $2,000 allowance for hearing aids every 3 years. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing services have not been met.
The Plan benefit does not provide for dehumidification services. In addition, Medicare does not reimburse separately for sales tax. Therefore, we decided that the Plan does not have to pay for dehumidification of hearing aids (V5299) and sales tax (S9999) provided on June 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric services rendered on February 5, 2021 to March 31, 2021.
You asked the Plan to pay for these services. You say that the provider has been covered in the past. The Plan denied your request. The Plan says the provider has opted out of Medicare.
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 the psychiatric services rendered on February 5, 2021 to March 31, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient individual psychotherapy services (90837) provided on May 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient individual psychotherapy services (90837) provided on May 25, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and diagnostic services provided on May 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that the provider said they accepted your insurance. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The Plan cannot be held responsible for possible misinformation regarding network status given by a provider. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit and diagnostic services provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for out of network cardiology services.

You asked the Plan to provide coverage for out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must provide coverage 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 provide coverage for these items/services. Therefore, we decided that the Plan does not have to provide coverage for out of network cardiology services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). You say that you have rheumatoid arthritis and would like the Plan to reevaluate the decision. The Plan denied your request. The Plan says that the certification dated September 10, 2021, documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on May 3, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on May 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on April 1, 2021.

You asked the Plan to pay for an x-ray. You say that this was provided in an appropriate place of service. The
Plan denied your request. The Plan says this was not billed with the correct place of service code.

The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing
services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of
service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.

We looked at the file and Medicare rules. The record shows that the enrollee was a registered inpatient at the
time the service at issue was provided, but this service was not billed with POS code 21.

Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on April 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612), for the enrollee.
You asked the Plan to pre-approve the service. You say that the services are necessary. The Plan denied your request. The Plan says your request is not medically necessary because according to guidance CPT code 22633 cannot be used together with CPT code 22612.
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 service.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the plan is correct in denying the 22612 fusion CPT code 22612 at the same level. If the exploration of fusion code is used, then fusion cannot be used at the same level. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on June 8, 2021.

You asked the Plan to reduce the copayment for the arthrocentesis procedure. You say that you were overcharged for this procedure as you do not believe that surgery was performed. You said that had you gone to an orthopedic doctor and they performed this procedure, your copayment would have been a lot less. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($249.54) 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 $390 copayment for outpatient surgery and services at an outpatient hospital facility.

You have been asked to pay a $390 copayment for the arthrocentesis procedure. Arthrocentesis is considered a surgical procedure, so the arthrocentesis procedure falls within the outpatient surgery and services at an outpatient hospital facility 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 the arthrocentesis procedure you had at an outpatient hospital facility on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services (D7210) provided on July 27, 2021.
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you have a $1500 combined allowance for supplemental preventive and comprehensive dental services every year. The Plan says that you are responsible for any amount over and above the allowance amount per your contract with the Plan. The Plan says that the total amount of dental services you received for the 2021 plan year was $1659 ($1459 + $200=$1659). The Plan says that your full annual dental allowance of $1500 ($1659 total charges-$1500 plan payment=$159 member liability) was paid. The Plan says you are responsible for the remaining amount of $159.
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. We looked at the file, the Plan's contract and Medicare rules. The Plan's contract shows you have a $1500 combined allowance for supplemental preventive and comprehensive dental services every year. You are responsible for any amount over and above the allowance amount per your contract with the Plan. The file shows that the total amount of dental services you received for the 2021 plan year was $1659 ($1459 + $200=$1659) for dates of service June 30, 2021 and July 27, 2021. The file shows that your full annual dental allowance of $1500 ($1659 total charges-$1500 plan payment=$159 member liability) was paid. You are responsible for the remaining amount of $159. Therefore, we decided that the Plan does not have to pay additionally for the dental services (D7210) provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (U0002 & 77002) provided May 17, 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 claim cannot be paid as billed.

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 codes U0002 & 77002 are not supported in the medical record. Specifically, payment for procedure U0002 was issued under payment for another code billed. There is no primary procedure billed for addon code 77002. 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 (U0002 & 77002) provided May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone for the enrollee.
You asked the Plan to pre-approve this drug. You say that the enrollee needs this to treat polymyalgia rheumatica. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram represented by code 93010 provided on January 25, 2021.
You asked the Plan to pay for code 93010. 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 as billed.
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 93010 has a bundled relationship with code 27752 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 the electrocardiogram represented by code 93010 provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field test provided on June 8, 2021.
You asked the Plan to waive the copayment for the visual field test. The Plan denied your request. The Plan
says the correct copayment has been applied to the adjusted claim.
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 Vision Care.
You have been asked to pay a $35 copayment for the visual field test. The visual field test falls within the
Vision Care benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a visual field test provided
on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded as 64493 and 64494 provided on April 14, 2021.
You asked the Plan to pay for the injection services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says these claims have denied correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for both CPT codes 64493 and 64494 is 1. The MAI value for these codes is 2. You billed 4 units of these code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded as 64493 and 64494 provided on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on June 12, 2021.

You asked the Plan to pay for ambulance services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.

The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). 

We looked at the file and Medicare rules. The first billed diagnosis code on the claim for the service at issue, T50.905A, is an adverse effect code that requires the nature of the effect to be coded first. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met.

Therefore, we decided that the Plan does not have to pay for ambulance services (A0427, A0425) provided on June 12, 2021.