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

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r (CPT code U0003) provided to the enrollee on June 12, 2020.
You asked the Plan to pay for the testing. You say that this is payable by Medicare and they were denied as experimental in error. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique (CPT code 87635), Clinical Laboratory Improvement Amendments (CLIA) waived test, was billed and paid to the provider on the same date of service. Per American Medical Association (AMA) and CPT assistant, Coronavirus CPT coding and guidance, both CPT and Healthcare Common Procedure Coding System (HCPS) codes should not both be reported on the same claim. Mutually exclusive edits consist of combinations of procedures that different in technique or approach but lead to the same outcome. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive. The records provided did not support distinct and separate procedures. Therefore, separate charges for code(s) U0003 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r (CPT code U0003) provided to the enrollee on June 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mouth lesion biopsy (40808) and the 
tongue biopsy (41100) provided on June 24, 2021. 
 
You asked the Plan to waive 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 services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. 

You have been asked to pay a $225 copayment for the Medicare-covered surgery provided at an outpatient 
hospital facility. 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 mouth lesion biopsy (40808) 
and the tongue biopsy (41100) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wearable, automatic, external 
defibrillator with integrated electrocardiogram analysis (K0606) provided November 19, 2020. 
 
You asked the Plan to waive the copayment for the automatic external defibrillator. You say that please pay 
this bill if required. The Plan denied your request. The Plan says this claim was processed with the correct cost 
share applied per the Evidence of Coverage. 
 
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 20% 
coinsurance for Medicare covered benefits for Durable Medical Equipment (DME) and Related Supplies. 

You have been asked to pay $540.99 ($2704.94 allowed amount x 20% coinsurance) for the automatic external 
defibrillator. The automatic external defibrillator falls within the Durable Medical Equipment (DME) and 
Related 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 the wearable, 
automatic, external defibrillator with integrated electrocardiogram analysis (K0606) provided November 19, 
2020.
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 surgeon on 
May 25, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you have not had to pay 
copayments for follow-up appointments before. 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 $40 
copayment for visits with a specialist.

Records show that you had a colonoscopy procedure on May 17, 2021.  According to Medicare rules, follow-
up visits during the postoperative period are included in the cost of the surgery.  The Medicare-allowed 
postoperative period for the procedure you had was 0 days.  Because of this, the cost of the follow-up is not 
part of the surgery and separate cost sharing can apply. You have been asked to pay a $40 copayment for the 
office visit. The office visit falls within the visits with a specialist 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 office visit you had with a surgeon on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on May 12, 2021.
You asked the Plan to pay for the resin-based composite. You say that you do not understand why this service is not covered under your dental allowance. You also say that you were advised that the dental allowance would cover $300 worth of services per year. The Plan denied your request. The Plan says this service is not covered.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2331) provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on April 6, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should e paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 must 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 imaging services provided to the enrollee on April 
6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nursing facility telehealth visit provided on May 5, 2021. 
 
You asked the Plan to pay for telehealth visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because a subsequent 
telehealth service was billed by the same provider on April 21, 2021 which is less than 30 days prior to this 
visit. 
 
The Plan must follow Medicare rules. Medicare rules say that subsequent nursing facility care services are 
limited to one telehealth visit every 30 days.  
 
We looked at the file and Medicare rules. A covered subsequent nursing facility care telehealth service was 
previously provided on April 21, 2021; therefore, 30 days had not passed before this service was provided. 
Based on this information, we decided that Medicare rules for coverage of telehealth visit have not been met. 
Therefore, we decided that the Plan does not have to pay for a nursing facility telehealth visit provided on May 
5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on March 23, 2021. 
 
You asked the Plan to pay for office visit 99213. You say that it was your understanding that this was 
approved. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
code 99213 has a bundled relationship with code 17000 and cannot be paid separately without an appropriate 
modifier. 
 
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 office 
visit 99213 has a bundled relationship with code 17000 and cannot be paid as billed. This code cannot be paid 
as a separate line item without an appropriate modifier, which was not included on this claim. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (99213) provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam (92004) provided on March 20, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that this was a routine eye exam provided by an in-network provider and should have a $0 copayment. The Plan denied your request. The Plan says this copayment was assessed 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 $10 copayment for Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eye exams when they are received from a provider who participates in the Plan's specified routine vision network. 

You have been asked to pay a $10 copayment for the eye exam. The eye exam in this case was billed with a medical eye exam code but was only billed with routine refractive diagnoses. It is possible that this was a routine eye exam; however, it was received from a provider who does not participate in the Plan's routine vision network and cannot be covered as a routine eye exam. Medical eye exams to diagnose and treat diseases and conditions of the eye require a $10 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 waive the copayment for the eye exam (92004) provided on March 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be met in a lower level of care. 

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have documented skilled nursing or skilled therapy needs. The enrollee appears to be functioning at or near 
his baseline. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can 
be provided at a lower level of care. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were admitted with dyspnea and hypoxia due to Coronavirus infection. The 
record indicates that you require nasal canula oxygen, intravenous solumedrol and general medical care. You 
continue to receive acute care services, and these have not been denied. The medical record does not indicate 
that you require services that you are not currently receiving but that would be available at the LTACH facility. 
The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fluid Flow injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee 
osteoarthritis. He has tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular 
steroid injections. The use of Fluid Flow for this condition is considered experimental/investigational in nature 
and not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Fluid Flow injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that your records show you do not have an illness complex enough 
to require continued inpatient hospital care with daily doctor visits and specialized nursing for more than 25 
days. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. Our physician reviewer found 
that your condition does not meet Medicare criteria for LTACH services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM).

You asked the Plan to pay for the CGM. You say that you want to appeal the denial of the CGM for the
enrollee. The Plan denied your request. The Plan says there was no proof of delivery document that matched
the date of service on the claim submitted by the provider for this member.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in
this case. The record shows that the Plan made several attempts to obtain the necessary documentation without
success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the office visits provided on January 5, 2021, and March 9, 2021.
You asked the Plan to waive the copays for the services provided. You say that you were told there is a $0 copay for primary care doctors. The Plan denied your request. The Plan says the claim processed 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 $10 copay for out-of-network services in a primary care physician's office. The file shows you received services from an out-of-network provider. You have been asked to pay a $10 copay for each visit at issue. The services fall within the physician 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 copays for the office visits provided on January 5, 2021, and March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0210) and periodontal maintenance (D2010) provided by a participating provider on July 9, 2021.
You asked the Plan to waive the coinsurance for a periodic oral evaluation and periodontal maintenance. You say that you went for a regular cleaning, and you should not be charged. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for preferred dental plan/class 2. You have been asked to pay a 50% coinsurance of the allowed amount for a periodic oral evaluation and periodontal maintenance. The total allowed amount is $203. The total amount you are being asked to pay is
$101.50 ($203 x 50% = $101.50). A periodic oral evaluation and periodontal maintenance falls within the preferred dental plan/class 2 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 a periodic oral evaluation (D0210) and periodontal maintenance (D2010) provided by a participating provider on July 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) (CPT code G0453) provided to the enrollee on January 27, 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 service is 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. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between G0453 and 95887. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) (CPT code G0453) provided to the enrollee on January 27, 2021.