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

 We decided that the Plan does not have to issue reimbursement for the Methadone treatment (G2067) rendered by the out-of-network (OON) provider from July 1, 2021, through July 30, 2021.  

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 issue reimbursement 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 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 issue reimbursement for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the Methadone treatment (G2067) rendered by the out-of-network (OON) provider from July 1, 2021, through July 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on July 2, 2021.  

You asked the Plan to pay for the hot or cold packs therapy (97010). You say that the claim processed out-of-network resulting in incorrect payment. You say that authorization is not needed as a contracted provider and the claim should be processed at the in-network level. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  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 97010 is application of a modality to 1 or more areas; hot or cold packs.  

We find that CPT code 97010 is not supported in the medical record. Specifically, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy (97010) have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (52332, 76000, 74280, 88300, J7120, J3010, J2405, J1170, J0696, J0330, C2617, C1769, C1758, Q9967) provided on March 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for outpatient services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 outpatient services (52332, 76000, 74280, 88300, J7120, J3010, J2405, J1170, J0696, J0330, C2617, C1769, C1758, Q9967) provided on March 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for services you received in a vascular surgeon's office on October 8, 2021.  

You asked the Plan to waive the copayment for the vascular surgery services. You say that you believe you paid your copayment up front and now you are being charged an additional copayment for tech services. The Plan denied your request. The Plan says you were only charged one $40 copayment for this date of service.  You were not charged for any additional services on this date.  

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 specialist services.   

You have been asked to pay a $40 copayment for the vascular surgery services. The vascular surgery services falls within the specialist 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 copayment for services you received in a vascular surgeon's office on October 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and two localized deliveries of antimicrobial agents (D4381 x2) provided on June 9, 2021.  

You asked the Plan to pay for the adjunctive pre-diagnostic test and localized deliveries of antimicrobial agents. You say that you were dissatisfied with the previous provider's dental work, so you went to this treating provider who found the infection. The Plan denied your request. The Plan says these services are 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 adjunctive pre-diagnostic test (D0431) and two localized deliveries of antimicrobial agents (D4381 x2) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on May 19, 2021.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you were advised that your dentist was in-network with the Plan. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded.

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, intraoral x-rays are limited to one procedure code per calendar year. The record shows that you received a first intraoral periapical x-ray (D0220) on August 30, 2021 and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (99100) provided April 19, 2021.  

You asked the Plan to pay for anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not eligible for separate payment.  

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 code 99100 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "B" and payment is always bundled with a primary service. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bioelectric therapy and nutri-pharmaceutical blend injections (G0283 and J3420) provided on August 31, 2021.  

You asked the Plan to pay for the bioelectric therapy and nutri-pharmaceutical blend injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed service is considered experimental. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bioelectric therapy and nutri-pharmaceutical blend injections have not been met. With review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Therefore, we decided that the Plan does not have to pay for the bioelectric therapy and nutri-pharmaceutical blend injections (G0283 and J3420) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for diabetic supplies (K0553) provided July 20, 2021.  

You asked the Plan to pay for the diabetic supplies. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  

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 relevant medical records which support medical necessity for the supplies provided in this case. The record does not show that the ordering physician discussed the need for these items with the enrollee.  

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 diabetic supplies (K0553) provided July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on September 16, 2021.

You asked the Plan to pay more for the periodontal maintenance. You say that the claim is being billed for periodontal maintenance and not the service of teeth cleaning which is what you received. You also say that you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says you have a 70% coinsurance for in-network periodontal maintenance.

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 responsible for a 70% coinsurance for a periodontal maintenance (D4910) that is received in-network. Therefore, we decided that the Plan does not have to pay more for the periodontal maintenance (D4910) provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided May 19, 2021.  

You asked the Plan to pay for a pneumatic compression device. You say that this device was medically necessary. The Plan denied your request. The Plan says this device was used during a surgical procedure and payment is included in the facility payment.  

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 

PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for arthrocentesis provided on June 15, 2021.

You asked the Plan to waive the deductible for arthrocentesis. You say that you disagree with the deductible charges because the services were provided in an office. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received arthrocentesis at an outpatient hospital facility on June 15, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had only paid $85.56 toward the $750 deductible. Therefore, you are responsible to pay the allowed amount of $276.23.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time arthrocentesis was received on June 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for arthrocentesis provided on June 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 30, 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 an 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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a colectomy (44146) provided on June 8, 2020.

You asked the Plan to pay for a colectomy. You say that this is supported in the records. The Plan denied your request. The Plan says this claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for a colectomy was not filed until October 5, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a colectomy (44146) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 7, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you were there for 5 minutes and they only told you what you already knew. You say that you should not owe another $35. The Plan denied your request. The Plan says you have been 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 a $35 copayment for each specialist visit.   You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visit provided on October 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on March 5, 2021.

You asked the Plan to pay for the subsequent hospital care. You say that this appeal should be granted because the services provided were medically necessary and meet all applicable professionally recognized standards of healthcare. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a cystourethroscopy procedure (52356)
provided on August 17, 2021.

You asked the Plan to waive the cost-sharing for a cystourethroscopy procedure. You say that you do not
remember having a medical deductible under your plan. The Plan denied your request. The Plan says the
correct cost-sharing was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $1000 deductible which applies to Medicare-covered surgery or other
services provided to you at an ambulatory surgical center. Your contract also says that you must pay a $150
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center.

The item or service you asked the Plan to waive the cost-sharing for falls within the "Outpatient Surgery and
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000
deductible which applies to Medicare-covered surgery or other services provided to you at an ambulatory
surgical center. This cost sharing is a contractual obligation that had not been met at the time a
cystourethroscopy procedure was received on August 17, 2021. You have also been asked to pay a $150
copayment for a cystourethroscopy 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 cost-sharing for a
cystourethroscopy procedure (52356) provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a laminectomy, facetectomy and foraminotomy (63047-59) provided on November 24, 2020.  

You asked the Plan to pay for a laminectomy, facetectomy and foraminotomy. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.  

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, this is a column II code that was performed in the same encounter and on the same spinal levels as the column I code, 22633. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for a laminectomy, facetectomy and foraminotomy (63047-59) provided on November 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2331) provided on October 19, 2021.

You asked the Plan to pay for the resin-based composite. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered benefit.

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 October 19, 2021.