Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on August 19, 2021.  

You asked the Plan to pay for the first intraoral periapical x-ray. You say that the periapical x-ray was needed because your tooth was so bad. You also say that it was not your fault that your tooth broke, and you needed the additional x-ray. The Plan denied your request. The Plan says you were not eligible for an additional periapical x-ray on August 19, 2021.  

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, you are limited to four periapical x-rays in a 12-month period. The record shows that you received periapical x-rays on September 24, 2020, November 3, 2020, and March 29, 2021 and your periapical x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hereditary cardiovascular profiling (81404, 81442, 81479) provided on April 13, 2021.  You asked the Plan to pay for hereditary cardiovascular profiling. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.  We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular profiling have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular profiling (81404, 81442, 81479) provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (88104, 88305, 88312, 88361) provided  May 11, 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 billed codes are not separately payable.  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 88104, 88305, 88312, & 88361 are not supported in the medical record. Specifically, the codes billed have a professional component / technical component indicator of 1. The services were provided in the inpatient hospital setting and were not billed with a required modifier. 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 (88104, 88305, 88312, 88361) provided  May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 21, 2021, to August 28, 2021.  

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not think that you should be charged an additional copayment. The Plan denied your request. The Plan says the correct copayment 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 $350 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.    

You have been asked to pay a $350 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,475 ($295 x 5 days = $1,475). An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided by a participating provider on August 21, 2021, to August 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for a debridement of subcutaneous tissue (11042) performed on July 14 and July 21, 2021.  

You asked the Plan to waive the copayments for a debridement of subcutaneous tissue. You say that you were misinformed about the required copayment and should not have to pay. The Plan denied your request. The Plan says the correct copayments were 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 $295 copayment for Medicare-covered surgery or other services provided at an outpatient hospital.   

You have been asked to pay a $295 copayment for each instance of a debridement of subcutaneous tissue for a total of $590. A debridement of subcutaneous tissue falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 copayments for a debridement of subcutaneous tissue (11042) performed on July 14 and July 21, 2021.   

Your complaint about receiving erroneous or incomplete information from the provider about your cost-sharing responsibilities is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 13, 2021.  

You asked the Plan to pay for the services. You say that the treatment sought was medically necessary to treat the enrollee based on their medical condition. The Plan denied your request. The Plan says this service is not covered by Medicare.  

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.   

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-share for the myocardial perfusion imaging, tomographic (SPECT) scan (78452), cardiovascular stress test (93015), and adenosine injection (J0153) provided on August 4, 2021.  You asked the Plan to waive the cost-share for the outpatient tests and injection. You say that these services should all be covered by the one copayment. The Plan denied your request. The Plan says this claim was processed correctly, and the cost-sharing was assessed in accordance with your contract.  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 $200 copayment for each type of Medicare-covered diagnostic radiology service, including MRI, CT scans, Nuclear Scans and PET scans, per date of service. If the doctor provides you services in addition to outpatient diagnostic and therapeutic radiology services, separate cost sharing may apply. The contract says there is a $35 copayment for each outpatient x-ray, diagnostic procedure and test. If a Medicare Part B drug is used during an outpatient diagnostic test, 20% cost share for Part B drugs also applies.  You have been asked to pay a $200 copayment for the SPECT imaging service, which is a nuclear scan and therefore falls under the Medicare-covered diagnostic radiology services benefit category. You have also been asked to pay a $35 copayment for the cardiovascular stress test, which falls under the outpatient diagnostic procedures benefit category. You also received an adenosine injection on this date, for which the Plan's allowed cost is $3.60 and 20% coinsurance applies ($3.60 x 20% = $0.72). This means that you have been asked to pay the correct amount for these services 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 cost-share for the myocardial perfusion imaging, tomographic (SPECT) scan (78452), cardiovascular stress test (93015), and adenosine injection (J0153) provided on August 4, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a complex cataract surgery to be rendered by an out-of-network (OON) surgeon.  

You asked the Plan to pre-approve the OON complex cataract surgery. You say that the enrollee's requires complex cataract removal which cannot be performed by network providers. The OON referral is warranted. The Plan denied your request. The Plan says that there are network providers able to safely perform a standard cataract removal. There is no medical need for a complex procedure, so OON referral is not required.  

The Plan follows Medicare rules. Medicare rules say that Plans may restrict enrollees to a network of providers, but must arrange specialty care OON when network providers are insufficient.   

The Plan failed to provide a list of network providers that were confirmed to be able to perform the complex cataract removal.   

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 OON complex cataract surgery. Our reviewer says that the request for complex cataract removal from an OON surgeon is considered medically reasonable and necessary in this case. Our physician reviewer found the patient had complaints of poor vision. Although no specific activities were listed as affected, the physician's appeal letter indicated that there was risk of falling due to poor vision. The evidence of visual disability is supported by visual acuity of 20/200 and cataract on examination.  Furthermore, the patient's documented small pupil size with dilation demonstrates that complex cataract surgery is warranted. The LCD states that "a miotic pupil which will not dilate sufficiently" and requires devices for pupil expansion, meets criteria for complex cataract extraction coverage.  

We looked at this physician's review, the file, and Medicare rules. Since the complex removal is medically necessary and no network providers were identified by the Plan, we find that OON care must be arranged. Based on this information, we decided that Medicare rules for coverage of the OON complex cataract surgery have been met. Therefore, we decided that the Plan has to pre-approve a complex cataract surgery to be rendered by an out-of-network (OON) surgeon.   

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: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for Fundus photography provided on August 20, 2021.  

You asked the Plan to pay for Fundus Photography. You say that this should be covered because it is to check the health of the eyes and it is basic standard of care to check for disease that could cause blindness. The Plan denied your request. The Plan says Fundus Photography is not a covered vision benefit and not covered by Medicare.  

The Plan follows Medicare rules. Medicare rules say Fundus Photography is not covered for routine screening.  

We looked at the file and the Medicare rules. Medicare says that Fundus Photography is not covered for routine screening. Therefore, we decided that the Plan does not have to pay for Fundus Photography provided on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory services (82570, 84156, 81001, 82043) provided on July 22, 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 $10 copayment for each Medicare-covered laboratory test.   

You have been asked to pay a $10 copayment for the Medicare-covered laboratory test provided. 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 laboratory services (82570, 84156, 81001, 82043) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (CPT code 20611) provided to the enrollee on July 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 documentation does not support the services billed.  

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 pay for the service. Our physician reviewer found CPT code 20611 -Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting billed to the health plan for services provided on July 27, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to support billing 20611 RT, therefore, 20611 RT is not eligible for additional reimbursement.  

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 pay for arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (CPT code 20611) provided to the enrollee on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a CT scan of the abdomen and pelvis (74177) provided on August 25, 2021.  You asked the Plan to waive the coinsurance for a CT scan of the abdomen and pelvis. You say that you were not expecting to be charged for the procedure at issue because it was ordered by your doctor. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance up to $75 a day for Medicare-covered diagnostic radiology services.   In this case, the Medicare-allowed charge for the services at issue is $443.55, 20% of which is $88.71. You have therefore been asked to pay the maximum coinsurance per day of $75 for a CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis 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 coinsurance for a CT scan of the abdomen and pelvis (74177) provided on August 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on June 11, 2021.  You asked the Plan to pay for the transportation services. You say that you do not agree with the plan's request for recoupment. You also say that the services were medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 pay for the transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the provided documentation does not support that other means of transport (such as stretcher van) were contraindicated for this patient on June 11, 2021. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on June 11, 2021. The reviewer also found that the documentation does not support that the ambulance transport on June 11, 2021, was medically reasonable and necessary for the enrollee.  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 transportation services have not been met. Specifically, the file does not support that other means of transport were contraindicated for the enrollee on June 11, 2021. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and ground mileage (A0425) provided on June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 93010) provided to the enrollee on May 7, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the appropriate modifier was not 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, the CPT Code Manual definition of code 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only."  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 says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical documentation of an external cardioversion and electrocardiography (ECG) was not included. CPT 93010 would be covered if this procedure was performed after the cardioversion as a follow up. However, this procedure should be reported with an appropriate modifier.   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 imaging services (procedure code 93010) provided to the enrollee on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the inpatient care provided from May 31, 2020, to June 1, 2020.  You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of diagnosis code J96.20 is supported. The Plan denied your request. The Plan says the billing of diagnosis code, J96.20 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code, J96.20, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 pay an additional amount for the inpatient care. Our physician reviewer found the provided documentation indicates that the enrollee with a history of chronic obstructive pulmonary disorder (COPD) was maintained on home oxygen on 2 liters and on evaluation in the emergency department was in respiratory distress and required 4 Liters of oxygen. The reviewer found that with the additional oxygen, the enrollee had no complaints of respiratory distress, cyanosis, tachypnea or progressive dyspnea. The reviewer found that the provided documentation does not demonstrate any complaints of respiratory distress during the hospitalization with the increased oxygen supplementation. Therefore, the reviewer found that the provided documentation did not support the billing of diagnosis code J96.20, acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient care provided from May 31, 2020, to June 1, 2020.