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

We decided that the Plan does not have to pay for procedure code 77063 billed for date of service October 30, 2020.
You asked the Plan to pay for procedure code 77063. You say that you have attached records to support procedure code 77063. The Plan denied your request. The Plan says that because the primary procedure code that this add-on code was related to (code 77067) was denied, payment for the add-on code of 77063 cannot be made.
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 procedure code 77063 is an add-on code. The primary code of 77067 was billed on a separate claim, but it was denied due to no authorization. Because there is no payable primary code, the add-on code cannot be paid. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 77063 billed for date of service October 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70480 billed for date of service September 5, 2021.
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for this code is bundled into the payment for code 70450.
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 procedure code 70480 is a column II code to column I code 70450.
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 procedure code 70480 billed for date of service September 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335), eligible clinician attests to documenting in the medical record they obtained (G8427), and patient screened for tobacco use and identified as a tobacco non-user (G9903) provided on June 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit, eligible clinician attests to documenting in the medical record they obtained, and patient screened for tobacco use. You say that you do not have authorization
ahead of time because your practitioners get a list of patients to see the day that they go to the nursing facility, leaving them no time to secure an authorization. You also say that the enrollee's primary care physician was called to get a retrospective authorization, but their office would not provide one because they never saw this enrollee in their office. The Plan denied your request. The Plan says the treating provider is not a network provider with the Plan, and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that these services are not urgent or emergent, nor were they 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 domiciliary or rest home visit (99335), eligible clinician attests to documenting in the medical record they obtained (G8427), and patient screened for tobacco use and identified as a tobacco non-user (G9903) provided on June 29, 2021 by an out-of-network (OON) provider.
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 the requested LTACH admission is
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission 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 admission is not medically necessary. Our physician reviewer found there is no
documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving
appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are
not available at the acute care hospital where he is currently receiving care. There are no services available at
the LTACH that the enrollee requires that are not available at the health care setting being offered by the health
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis
and condition of 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 9, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you were told that having staples removed would be included in a previous emergency room charge. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay the allowed amount of $64.82, which is less than the $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on September 9, 2021.
We note your complaint that you were told that having the staples removed would be included in a previous charge. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan and a duplex scan and does not
have to waive the coinsurance for medical supplies provided from July 29, 2021, to August 6, 2021.
You asked the Plan to waive the copayments for a CT scan and a duplex scan and to waive the coinsurance for
medical supplies. You say that you do not understand the difference in charges and how your benefits list a $0
copayment to 20% coinsurance. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160
copayment for radiological diagnostic services and 20% coinsurance for medical supplies.
You received a CT scan on July 29, 2021. Therefore, you are responsible to pay the $160 copayment.
You received medical supplies on July 29, 2021. The total allowed amount is $13.75 and 20% of that is $2.75.
You received a duplex scan on August 6, 2021. Therefore, you are responsible to pay the allowed amount of
$141.79, which is less than the $160 copayment.
The total amount you owe is: $304.54.
You have been asked to pay the total amount of $304.54 for a CT scan, a duplex scan and medical supplies. A
CT scan, a duplex scan and medical supplies fall 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 copayments for a CT scan and a duplex
scan and does not have to waive the coinsurance for medical supplies provided from July 29, 2021, to August
6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services provided on January 10, 2021, through April 6, 2021.
You asked the Plan to pay for the home health aide services. You say that you would like reconsideration for the home health aide services. The Plan denied your request. The Plan says an Explanation of Benefits (EOB) from your primary insurance carrier is needed before this claim can be reconsidered.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer.
However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has the Plan directed you to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the home health aide services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for home health aide services provided on January 10, 2021, through April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on August 3, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were not informed the doctor is no longer in the network. You say that you wouldn't have decided to go to the appointment if you knew this and you should not be responsible for the cost. The Plan denied your request. The Plan says the claim processed correctly.
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 Plan is only obligated to pay 50% of the allowed amount for a prophylaxis and periodic oral evaluation from an out-of-network provider. You are responsible for any amount greater than the payment made by the Plan to the out-of-network provider. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on August 3, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fourteen (14) extractions (D7140 x14) provided from May 28, 2019, to July 30, 2019.
You asked the Plan to pay for the extractions. You say that your claim was filed late due to the pandemic time of isolation. You also say that you were not able to get anyone at the clinic to get you the documents, and you would like to be partially reimbursed for these services. The Plan denied your request. The Plan says this claim was received on August 3, 2021 which is past the allowed 12-month timeframe.
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 these extractions was not filed until August 3, 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 the fourteen (14) extractions (D7140 x14) provided from May 28, 2019, to July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral L4-5, L5-S1 medial branch blocks for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity is not established as reasonable and 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 injections. Our reviewer says that
the requested injection is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's pain is associated with radiculopathy. The facet joint is not the main source of pain. The review has determined that the enrollee does not have a covered indication for the requested bilateral lumbar medial branch blocks as requested. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral L4-5, L5-S1 medial branch blocks for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 84443, 85025) and the chest x-ray (71046) rendered by the out-of-network (OON) provider on July 16, 2021.
You asked the Plan to pay for these services. 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (36415, 80053, 84443, 85025) and the chest x-ray (71046) rendered by the out-of-network (OON) provider on July 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care rendered on May 18,
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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. 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 nursing facility care rendered on May 18, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 26, 2021.
You asked the Plan to pay for the endodontic therapy. You say that you have been seeing this provider for over 30 years and you feel the Plan should pay at least 50%. The Plan denied your request. The Plan says this service is not a covered benefit 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 endodontic therapy (D3330) provided on August 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on July 13, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that a stretcher van was contraindicated for this patient on July 13, 2021.
The enrollee was reported to be medically stable and was in his private home and transported to a physician's office for a wound check. The provided records did not describe any acutely unstable condition which appeared to require any lifesaving or life-sustaining equipment.
Based on the medical records provided the documentation does not support that the ambulance transport on July 13, 2021 meets Medicare criteria for 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 18, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that Transcutaneous Electrical Nerve Stimulation (TENS) for chronic low back pain only when the enrollee is in an approved clinical study We looked at the file and Medicare rules. The file shows that the TENS therapy was not provided for the treatment of chronic low back pain as part of an approved clinical study. 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 transcutaneous electrical nerve stimulation (TENS) therapy rendered on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64490, the surgical trays coded A4550, and the moderate sedation services coded 99156 provided on May 26, 2021.
You asked the Plan to pay for the injection services, the surgical trays, and the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64490 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Code A4550 has a status code of "B". This means that payment for covered services is always bundled into payment for other services not specified. Payment for code 99156 is bundled within the injection services. These codes are not separately payable. Based on this information, we decided that Medicare rules for coverage of the injection services, the surgical trays, and the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64490, the surgical trays coded A4550, and the moderate sedation services coded 99156 provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (CxBladder Detect) provided to the enrollee on June 9, 2021.
You asked the Plan to pay for the services. You say that the enrollee's benefits cover this test. The Plan denied your request. The Plan says this service does not Medicare criteria to be medically reasonable and necessary, and cannot be approved.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found current evidence does not sufficiently support the use of this test vs other standard testing leads to
significantly better overall outcomes for similar clinical situations to justify standard testing methods.
Therefore, this request for CxBladder Detect will be considered not medically necessary at this time.
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 pay for laboratory services (CxBladder Detect) provided to the enrollee on June 9, 2021.