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

We decided that the Plan does not have to pay more for the outpatient services and self-administered drugs provided from June 10, 2021, through June 11, 2021.

You asked the Plan to pay more for the outpatient services and self-administered drugs. You say that the medical bills should be covered by the Plan, and you asked the provider to delay billing pending review of further payment. The Plan denied your request. The Plan says the claim was reprocessed toward your in-network benefits applying a $175 copayment to the outpatient procedure. The self-administered drugs remain denied as a non-covered service.

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 $175 copayment for diagnostic procedures and tests at an in-network outpatient hospital.

You have been asked to pay a $175 copayment for the outpatient services. The outpatient services fall within the "Outpatient hospital 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.

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 pay more for the outpatient services and self-administered drugs provided from June 10, 2021, through June 11, 2021.

Benefits for the self-administered drugs 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 waive the copayment for digital evaluation and management (E/M)
services provided on March 25, 2021.
You asked the Plan to waive the copayment for the digital E/M services. You say that you paid your balance in
full at the time of service and should not be billed for the remainder. 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 $45
copayment for provider services from a doctor other than your PCP.
You have been asked to pay a $45 copayment for the digital E/M services. The file shows you have already
paid $30.93, leaving a balance of $14.07. The digital E/M services fall 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 digital evaluation and management (E/M) services provided on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolaris testing.
You asked the Plan to pre-approve the Prolaris testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of this testing.
The Plan follows Medicare rules. Medicare rules say that the ProlarisTM assay is covered for men with favorable intermediate risk prostate cancer only when there is a Predominant Gleason grade 3 (i.e. Gleason score 3+4=7), percentage of positive cores <50%, and no more than 1 NCCN intermediate-risk factor). 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 Prolaris testing. Our reviewer says that the elements of the coverage criteria are not satisfied. The requested service cannot be recommended. Our physician reviewer found the record indicates that the enrollee has a stage T1c lesion with a Gleason score of 7 and a prostate specific antigen value of 23.7. The record indicates that the enrollee has more than one NCCN intermediate risk factor. 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 Prolaris testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the Prolaris testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray of the chest (71045) provided on August 20, 2021.
You asked the Plan to pay for the X-ray of the chest. You say that this was denied in error. The Plan denied your request. The Plan says an appropriate modifier was not billed with this claim.
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 71045 is a column II code to column I code 36558. 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 the X-ray of the chest (71045) provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on September 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 70544 is a column II code to column I code 70551. 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 the services (70544) provided on September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.

You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested service is 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 the Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated severe spinal stenosis at L3-L4 and L4-L5, the levels requested for treatment. The elements of the coverage criteria are not satisfied.

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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the control of nasal hemorrhage (30901) provided on April 17, 2021.

You asked the Plan to pay for the control of nasal hemorrhage (30901). You say that you disagree with the claim denying for the information not supporting the level of service billed. You say that payment of the claim should be reconsidered. The Plan denied your request. The Plan says CPT code 30901 is not supported. The Plan also says that the procedure performed is included in the evaluation and management service reported.

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 30901 is control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method.

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 control of nasal hemorrhage (30901). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided do not include sufficient documentation to validate that a control nasal hemorrhage was performed on April 17, 2021, therefore, this procedure cannot be verified. 

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 control of nasal hemorrhage (30901) have not been met. Therefore, we decided that the Plan does not have to pay for the control of nasal hemorrhage (30901) provided on April 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on February 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 drug testing provided on February 2, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on September 23, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, 2 views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046.
Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says there is a 190-day lifetime limit for inpatient psychiatric hospital days. The Plan states the enrollee's stay will not be covered by their plan beginning January 31, 2022.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The Health Plan has confirmed via the CMS website that the enrollee used 190 days of inpatient services in a psychiatric hospital through original Medicare. The enrollee's benefit maximum was exhausted as of January 30, 2022, for a total of 190 days of inpatient services in a psychiatric hospital. Coverage beyond 190-day lifetime limit is not covered by Medicare. Therefore, the Health Plan does not have to provide coverage for admission to inpatient mental health care beyond the 190-day maximum. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and preventive procedure (D1999) provided on September 28, 2021.

You asked the Plan to pay for the intraoral periapical x-rays and preventive procedure. You say that you were advised that all x-rays are covered by the Plan. You also say that you cannot afford to pay for these services because you live on a fixed income. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan.
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 first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), and preventive procedure (D1999) provided on September 28, 2021.

Your complaint about being misled by the provider's office 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the central venous catheter removal and fluoroscopic guidance for central venous access device placement provided by an out-of-network provider on September 17, 2021.
You asked the Plan to pay for the central venous catheter removal and fluoroscopic guidance for central venous access device placement. You say that the provider was unable to obtain authorization, but the surgeon provided services based on the patient's necessity. You say that previous claims have been paid and you are requesting retro authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and 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 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 central venous catheter removal and fluoroscopic guidance for central venous access device placement provided by an out-of-network provider on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81521, 81479) provided on July 22, 2021.

You asked the Plan to pay for genetic testing. You say that this is covered by Medicare. The Plan denied your request. The Plan says these codes cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81521 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. The rules also 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 81479 is unlisted molecular pathology procedure. 

We looked at the file and Medicare rules. Code 81521 is unlikely to impact therapeutic decision-making and is not covered. The records do not indicate what testing the unlisted code 81479 is being used to bill, meaning this code is not supported. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81521, 81479) provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete
mandibular denture (D5120) provided on September 29, 2021.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that
you needed new dentures because the old ones were causing problems such as soreness, dentures falling out
and were uncomfortable while eating. You also say that you were not aware that dentures are only covered
once every five years. The Plan denied your request. The Plan says these services exceed the maximum
allowed per period.
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, complete maxillary denture (D5110)
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record
shows that you received a complete mandibular denture (D5120) July 14, 2017, and a complete maxillary
denture (D5110) on October 17, 2017, and your complete maxillary denture (D5110) and complete mandibular
denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the
complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on September 29,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care rendered on August 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the submitted records do not support the billing of procedure code 99225.
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 99225 is Level 2 subsequent observation care for
evaluation and management of patient, including expanded problem-focused interval history and medical
decision-making of moderate complexity, typical time 25 minutes.
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 these services. Our reviewer says that the submitted records
do not support the billing of procedure code 99225. Our reviewer found the subsequent care documentation
does not support the level of care associated with code 99225. There is a more appropriate code to report for an
expanded problem focused history; expanded problem focused exam; and low complexity medical decision
making for which the documentation supports. When more than one evaluation and management code is
provided on the same date of service a modifier should be appended to support why services were medically
necessary.
We looked at this coder'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 pay for the subsequent observation care rendered on August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97814) outpatient office visit (99213) infrared light therapy (97026) provided September 1, 2021.

You asked the Plan to pay for the acupuncture services. You say that the denial says that acupuncture and related services are not covered when performed by a chiropractor. However, the doctor is not a chiropractor. He is an acupuncturist and doctor of Chinese medicine. The Plan denied your request. The Plan says the services are not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the health Plan contract says that acupuncture is only covered for chronic low back pain. The claim was billed with the diagnosis code M796.21 for pain in limb, hand, foot, fingers and toes. Infrared therapy is also not covered by Medicare. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97814) outpatient office visit (99213) infrared light therapy (97026) provided September 1, 2021.