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

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on March 17, 2021.
You asked the Plan to pay for the non-emergency ambulance transportation services. You say that the enrollee's conditions contraindicate transport by other means. The Plan denied your request. The Plan says this ambulance service is not covered.
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 non-emergency ambulance transportation services. Our reviewer says that the non-emergency ambulance transportation was not medically necessary. Our physician reviewer found that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on March 17, 2021. Documentation did 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 March 17, 2021. The documentation did not support that the ambulance transport on March 17, 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 non-emergency ambulance transportation services have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent.
You asked the Plan to pre-approve destruction by neurolytic agent. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary when specific criteria is met.
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 destruction by neurolytic agent. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that you do not meet the criteria for the requested procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of destruction by neurolytic agent have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82306) provided April 28, 2021.
You asked the Plan to pay for the lab services. You say that the tests were medically necessary. The Plan denied your request. The Plan says the services were not billed with a valid diagnosis code and the enrollee was advised the service would not be covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, Calcifediol testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (82306) provided April 28, 2021.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay for the abdominal aortography (75625). We decided that the Plan does not have to pay for the extremity angiography.
You asked the Plan to pay for the abdominal aortography (75625). You say that this should be paid as billed. The Plan says that this is not supported.
We decided that the Plan has to pay for the abdominal aortography (75625).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coding 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 abdominal aortography (75625). Our reviewer says that the reporting of code 75625 is supported while the use of modifier -59 for code 75710 is not supported. Our reviewer found in regard to 75625, the operative report states that an Omni flush catheter was placed into the abdominal aorta, which was used for imaging the aorta and iliac arteries. This clearly documents the services described by 75625. Code 75710 is part of the radiological supervision for the Column 1 procedure. The operative report does not support the use of -59 as this is not shown to be separate and distinct. 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 abdominal aortography (75625) have been met. Therefore, we decided that the Plan has to pay for the abdominal aortography (75625).
We also decided that the Plan does not have to pay for the extremity angiography.
The Plan follows Medicare rules. Medicare rules say that when an NCCI edit exist between two codes, only the Column 1 code is payable unless a clinically appropriate modifier is used. Code 75710 is a Column 2 code in relation to 37229. As noted above, the use of modifier -59 was not shown to be clinically appropriate. Based on this information, we decided that Medicare rules for coverage of the extremity angiography have not been met. Therefore, we decided that the Plan does not have to pay for the extremity angiography.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you
received from December 19, 2019, to January 28, 2020.
You asked the Plan to waive the copayment for the SNF services. You say that you were not notified that his
service would end. You stated that he was their fault you could not walk, so you shouldn't have to pay this
copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0
copayment per day for days 1-20, and a $172 copayment per day for days 21-100 for skilled nursing facility
services. Records show that you received 18 days of skilled nursing facility services prior to the dates of service in
question. From December 19, 2019 to January 18, 2020, you were in the SNF for 27 days. Two of these days
were charged no copayment, because they were the final two days of days 1-20 that have no copayment. For
the remaining 25 days, you were charged a copayment of $172 per day, for a total of $4300. However, you
only had $3404 remaining on your out-of-pocket maximum, so that is why you have been charged for these
SNF services. 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. This cost
sharing applies regardless of your satisfaction with the services received. Therefore, we decided that the Plan
does not have to waive the copayment for skilled nursing facility (SNF) services you received from December
19, 2019, to January 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdominal ultrasound (76700) provided on June 30, 2021.
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that you are being overcharged for the services received. The Plan denied your request. The Plan says the correct copayment 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 a $100 copayment for each day for a Medicare-covered ultrasound. You have been asked to pay a $100 copayment for an abdominal ultrasound. An abdominal ultrasound 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 copayment for an abdominal ultrasound (76700) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided June 9, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you need these services prior to knee surgery. The Plan denied your request. The Plan says these services are not covered under your benefits.
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
periodontal scaling and root planing - four or more teeth per quadrant (D4341) and periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter procedure provided in a urologist's office on June 10, 2021.
You asked the Plan to waive the copayment for the catheter procedure. You say that this procedure has been performed in the past with no copayment. The Plan denied your request. The Plan says this copayment was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for services obtained from a specialist. The enrollee has been asked to pay a $40 copayment for the catheter procedure. Because these services occurred in a urologist's office, the catheter procedure falls within the services obtained from a specialist benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the catheter procedure provided in a urologist's office on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. 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.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on June 18, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you do not feel you should be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 per visit for covered services to a medical facility or urgent care center.
You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 the urgent care visit provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing provided on June 23,
2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that the deep cleaning is
considered preventive and you cannot pay out-of-pocket for the remainder of the year. The Plan denied your
request. The Plan says $1,500 was already reimbursed to meet your maximum 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. Plan paid $1,500 toward your dental services received from April 26, 201, through June 23, 2021,
which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodontal
scaling and root planing provided on June 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after October 17, 2021.
You asked the Plan to pre-approve SNF care. You say that you are not capable of taking care of yourself at home and there is no way you can get home health. The Plan denied your request. The Plan says the denial of authorization for continued SNF care is correct.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after October 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on March 28, 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 
has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate 
line item. 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 March 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural steroid injection procedure you had at an outpatient hospital facility on May 25, 2021.

You asked the Plan to waive the copayment for the epidural steroid injection procedure. You say that you were not told there would be a copayment for this service. You said that you had no pain relief from the procedure. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient surgery or other services provided at an outpatient hospital facility. You have been asked to pay a $295 copayment for the epidural steroid injection procedure. The epidural steroid injection procedure falls within the outpatient surgery or other services provided at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.

Therefore, we decided that the Plan does not have to waive the copayment for the epidural steroid injection procedure you had at an outpatient hospital facility on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for deep sedation/general anesthesia (D9222) provided on
April 16, 2021.
You asked the Plan to hold you harmless for deep sedation/general anesthesia. You say that you do not
understand why this service would not be covered. The Plan denied your request. The Plan says that the service
at issue is not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for deep sedation/general anesthesia by a contract provider. The file does not show that the
Plan provided notice that deep sedation/general anesthesia would not be covered. Under Medicare rules, this
means deep sedation/general anesthesia is considered approved by the Plan. The code at issue is listed as a
covered benefit in the Summary of Dental Plan Benefits. The EOC is not adequate notice of non-coverage in
this case. Therefore, we decided that the Plan has to hold you harmless for deep sedation/general anesthesia
(D9222) provided on April 16, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision exam you had on June 3, 2021.
You asked the Plan to waive the copayment for the vision exam. You say that you are entitled to one free eye
exam per year, and this was routine. The Plan denied your request. The Plan says you were charged this
copayment correctly because this visit was not billed as a routine eye exam.
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 visits for the diagnosis and treatment of disease and injuries of the eye.
You have been asked to pay a $10 copayment for the vision exam. We looked at the medical records from this
visit. The records do not indicate that you received a routine eye exam. Rather, the records show that you
were evaluated for pseudophakia and puckering of the macula of the right eye. These services are medical in
nature and not part of a routine eye exam. That is why the vision exam falls within the visits for the diagnosis
and treatment of disease and injuries of the eye benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the vision exam you had on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014) provided on April 7, 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 service 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 $45 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. n asked to pay a $45 copayment for the Medicare-covered diagnostic vision exam 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 ophthalmological medical examination and evaluation, with initiation or continuation of a diagnostic and treatment program; comprehensive, established patient, 1 or more visits (92014) provided on April 7, 2021.