Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for the injection procedure coded as 20610. We decided that the Plan does not have to pay for the surgical trays coded as A4550.

You asked the Plan to pay for the injection procedure coded as 20610. You say that this should be covered. The Plan says that a decision was not made on code 20610, but payment cannot be made for A4550.

We decided that the Plan has to pay for the injection procedure coded as 20610.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

In this case, the Plan did not forward a valid denial rationale for code 20610. It is noted that the claim was denied due to a date of service or patient name discrepancy. There was no such discrepancy found on our review. The file included a report showing this was provided on the billed date of service. Therefore, we decided that the Plan has to pay for the injection procedure coded as 20610.

We also decided that the Plan does not have to pay for the surgical trays coded as A4550.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Code A4550 does not have a separate payment when billed on an ambulatory surgical center claim. Therefore, we decided that the Plan does not have to pay for the surgical trays coded as A4550.

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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 6, 2021 by an out-of-network (OON) provider    You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you moved and were finally able to receive dental appointments in the middle of the pandemic. You also say that you were assured you would be covered. The Plan denied your request. The Plan says the total $80 amount applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.  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 the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 6, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of tunneled intraperitoneal catheter (CPT code 49422) provided to the enrollee on August 11, 2021.
You asked the Plan to pay for the service. You say that the assistant was chosen by the operating surgeon completely at the surgeon's discretion and the assistant provider had no choice to not be on the case and ethically could not deny the services to the patient. The Plan denied your request. The Plan says this is not covered.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 49422. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the service have not been met.
Therefore, we decided that the Plan does not have to pay for removal of tunneled intraperitoneal catheter (CPT code 49422) provided to the enrollee on August 11, 2021.
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 September 1, 2020, to October 31, 2020.

You asked the Plan to waive the copayment for the SNF services. You say that the same services were fully paid for other months. The Plan denied your request. The Plan says you were charged this copayument correctly. The Plan says that you did not hit your maximum out-of-pocket until after the claims for these services processed.

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 for days 1-20, and a $178 copayment per day for days 21-100 for skilled nursing facility care.

Records show that you were in the SNF from August 20, 2020, to October 31, 2020, for a total of 72 days. You were not charged a copayment for the first 20 days of this stay (August 20, 2020, to September 9, 2020.) You were then charged a copayment of $178 per day for the remaining 52 days, for a total of $9256. However, you only had $5,097.84 remaining on your out-of-pocket maximum for the year, so that is all you are being charged for this SNF stay. You have been asked to pay a $0 copayment for days 1-20, and a $178 copayment per day for days 21-100 for the 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. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from September 1, 2020, to October 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and immunizations provided on August 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON medical services. You say that this should be paid due to medical necessity. The Plan denied your request. The Plan says this visit was with an OON provider without authorization or referral from the primary care provider.
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 office visit and immunizations provided on August 17, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the radical nephrectomy provided on September 7, 2021 billed with code 50545.

You asked the Plan to provide additional reimbursement for the radical nephrectomy procedure. You say that you paid $7000 for this procedure and feel that the Plan has not reimbursed the full cost. The Plan denied your request. The Plan says this procedure was reimbursed based on the Medicare allowed rate for this locality.

The Plan must follow Medicare rules. Medicare rules say that providers must accept Medicare allowable rates as payment in full for services provided to Medicare beneficiaries.

Though you have paid more than the Medicare allowable for this service, the Plan cannot be obligated to pay more than this amount. Therefore, we decided that the Plan does not have to provide additional reimbursement for the radical nephrectomy provided on September 7, 2021 billed with code 50545.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cleansing wipes.
You asked the Plan to pre-approve the wipes. You say that you are unable to bathe due to a skin condition. The
Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve cleansing wipes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health telehealth visit you had on August 10, 2021.

You asked the Plan to waive the copayment for the outpatient mental health telehealth visit. You say that you were told by the provider and by the Plan that this copayment would be waived. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they have phone records showing that you called them to ask about copayments being waived on August 2, 2021. On that date, you were advised that the copayment waiver ended on March 31, 2021.

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 $30 copayment for outpatient mental health visits.

You have been asked to pay a $30 copayment for the outpatient mental health telehealth visit. the outpatient mental health telehealth visit falls within the outpatient mental health visits benefit category. There is no provision in your contract for a waiver of this amount. 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 outpatient mental health telehealth visit you had on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81220, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81256, 81283, 81291, 81328, 81335, 81350, 81355, 81381) provided on July 13, 2020.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81220, 81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81256, 81283, 81291, 81328, 81335, 81350, 81355, 81381) provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT code 99308, 11043, 11042, and 17250) provided to the enrollee on June 21, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 services (CPT code 99308, 11043, 11042, and 17250) provided to the enrollee on June 21, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor sensors (K0553) provided on July 9, 2021.

You asked the Plan to pay for Freestyle Libre sensors. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules state that the information in the patient's medical record must adequately support the medical necessity for the DMEPOS item. 

The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided records do not discuss the need for a continuous glucose monitor or associated supplies. 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 Freestyle Libre continuous glucose monitor sensors (K0553) provided on July 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tradjenta.

You asked the Plan to pre-approve Tradjenta. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 pre-approve Tradjenta.

Benefits for Tradjenta 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 specialist services provided on June 29,
2021.
You asked the Plan to waive the copayment for specialist services. You say that you are being charged two
copayments and you disagree with the charges. 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 $30
copayment for specialist services.
You have been asked to pay a $30 copayment for specialist services. Specialist 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 specialist services provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on May 14, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 medical services provided to the enrollee on May 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the Neurobehavioral status exam (96116) provided on June 4, 2021.

You asked the Plan to pay for code 96116. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not supported.

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 96116 is Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour. 

We find that CPT code is supported in the medical record. Specifically, Medicare does not have diagnosis code limitations for code 96116. Based on this information, we decided that Medicare rules for coverage of code 96116 have been met. Therefore, we decided that the Plan has to pay for the Neurobehavioral status exam (96116) provided on June 4, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 3, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. The Plan already paid for 70496; therefore, this service is not able to be paid separately. Therefore, we decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for magnetic resonance imaging (MRI) and a computed tomography (CT) scan provided on June 4, 2021 and July 9, 2021.

You asked the Plan to waive the copayments for MRI and CT scan. You say that you were advised that your copayment would be $0 for these tests. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.

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 $75 copayment for outpatient diagnostic radiology services. There were 2 dates of service, resulting in a total copayment amount of $150.

You have been asked to pay $75 copayment for MRI and CT scan. MRI and CT scan 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 magnetic resonance imaging (MRI) and a computed tomography (CT) scan provided on June 4, 2021 and July 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on August 30, 2021.

You asked the Plan to pay for the services provided. You say that you were not notified of any changes to your out-of-network coverage. The Plan denied your request. The Plan says services furnished by a provider who has opted-out of participation with Medicare are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dermatology services provided on August 30, 2021.