Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for new patient, domiciliary or rest home visit (99326) provided on March 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for domiciliary or rest home visit. You say that it was medically necessary for the enrollee to receive the treatment by the doctor and you did not know that the facility failed to get pre-authorization for this enrollee, so you treated them anyways. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 new patient, domiciliary or rest home visit (99326) provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on April 1, 2021, by an out-
of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is a non-participating provider, and the 
referring provider is also a non-participating provider. The Plan also says that the Plan did not authorize any 
services for these providers.

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 drug testing (G0480) provided on April 1, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 and the osteopathic manipulative treatment (OMT) services coded 98928 provided on July 29, 2021.

You asked the Plan to pay for the office visit and the osteopathic manipulative treatment (OMT) 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 providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 99214 and 98928 are not supported in the medical record. Specifically, the documentation submitted did not indicate that a different anatomical site, a different condition or a related but unusual condition was addressed during the osteopathic manipulation visit. In addition, Osteopathic manipulative treatment of 7-8 body regions is not the correct CPT code to report when segmental/somatic dysfunction to at least seven regions is not indicated. The diagnoses reported do not support somatic/segmental dysfunctions that would warrant treatment. Based on this information, we decided that Medicare rules for coverage of the office visit and the osteopathic manipulative treatment (OMT) services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 and the osteopathic manipulative treatment (OMT) services coded 98928 provided on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services (full hereditary cancer panel)
provided to the enrollee on August 18, 2020.
You asked the Plan to pay for the services. You say that this should be covered based on Medicare guidelines.
The Plan denied your request. The Plan says there is no documentation of hereditary cancer, a risk for
hereditary cancer, or how the results of the test would guide therapeutic decision-making in regards to specific
medical condition.
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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found genetic testing would be indicated for 10 or more adenomatous polyps, or 5 or more serrated
polyps. There is no documentation any of this in the records.
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 genetic testing services (full hereditary cancer panel) provided to the enrollee on August 18,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on September 14, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you got your oral
examination before and do not understand why this one was not covered. The Plan denied your request. The
Plan says this service is not a covered benefit. The Plan also says that you signed a treatment plan showing the
problem focused limited oral evaluation (D0140) was not covered by your dental plan and acknowledging that
you would be fully responsible for the charge for this service.
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. The record shows that you signed a treatment plan with the provider's
office on September 14, 2021 acknowledging that you would be responsible for the charge for this service.
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation
(D0140) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulation to the extra-spinal regions (98943)
manual therapy techniques (97140) Electrical stimulation (G0283) Electrodes, pair (A4665) provided August 4,
2021.
You asked the Plan to pay for the chiropractic services. You say that you are appealing nonpayment of 98943,
97140, G0283 and A4556. The Plan denied your request. The Plan says these services are not covered when
rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for chiropractic manipulation to the extra-spinal regions (98943) manual therapy
techniques (97140) Electrical stimulation (G0283) Electrodes, pair (A4665) provided August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214-25) provided on August 26, 2021.
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that Modifier 25 is defined as
a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other
qualified health care professional on the same day of a procedure or other service.
We find that CPT code 99214-25 is not supported in the medical record. The office visit at issue was billed
with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management
(EM) service by the same physician or other qualified health care professional on the same day of a procedure
or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to
the treatment provided to the enrollee on this date of service. Based on this information, we decided that
Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not
have to pay for an office visit (99214-25) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 12, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the services provided. You say that you were unaware of the provider's out-of-
network status. The Plan denied your request. The Plan says the out-of-network services are not a benefit of
your plan.
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 office visit provided on January 12, 2021, by an out-of-network (OON)
provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 15, 2020, by an out-of-network provider. 

You asked the Plan to pay for psychotherapy services. You say that the services at issue are covered by Medicare. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met. 

 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 psychotherapy services (90834) provided on September 15, 2020, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous transhepatic portography rendered on
September 10, 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 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 75885 (percutaneous transhepatic portography with
hemodynamic evaluation, radiological supervision and interpretation) and 37241 (vascular embolization for
acquired venous malformation using imaging guidance with radiological supervision and interpretation, and
intraprocedural roadmapping).
Code 75885 is a column II code with a modifier indicator of 1 when billed with column I code 37241. Code
75885 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 percutaneous transhepatic portography rendered on September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a leg caddy/scooter (E0118) provided on July 15, 2021.
You asked the Plan to pay for a leg caddy/scooter. You say that the requested item is a necessity for your care.
The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare says that there is insufficient published clinical literature
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for
products billed using E0118 (crutch substitute).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a leg caddy/scooter have not been met. Specifically, this item is not a covered benefit of Medicare
or the Plan. Therefore, we decided that the Plan does not have to pay for a leg caddy/scooter (E0118) provided
on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 27, 2021.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
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 documentation shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on September 23, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that these 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 a domiciliary or rest home visit (99336) provided on September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast biopsy provided by an out-of-network provider on 
May 26, 2021.

You asked the Plan to pay for the breast biopsy. You say that the doctor that ordered the procedure has not 
gotten back to you. The Plan denied your request. The Plan says you do not have out of network benefits.

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 breast biopsy provided by an out-of-network 
provider on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit (G0463) on
May 21, 2020.
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you have only
just received the invoice for this date of service and should not have to pay such a late-issued bill. 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 $250
copayment for all other services performed at an outpatient facility not otherwise noted.
You have been asked to pay $110.45 for a hospital outpatient clinic visit. A hospital outpatient clinic visit falls
within the "Outpatient hospital services" benefit category. This means that you have been asked to pay less than
or equal to the full and correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a hospital outpatient clinic visit (G0463) on May 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an office visit and an electrocardiogram (EKG) provided on July 14, 2021.

You asked the Plan to waive the copayments for an office visit and an EKG. You say that you have never had a copayment for these services. The Plan denied your request. The Plan says the proper 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 $20 copayment for Medicare-covered non-radiological diagnostic services and a $45 copayment for services obtained from a specialist. On July 14, 2021, the total amount allowed for the EKG was $13.22 which is less than the copayment amount of $20, therefore you were only charged a $13.22 copayment.

You have been asked to pay a $58.22 copayment for an office visit and an EKG. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The EKG 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 copayments for an office visit and an electrocardiogram (EKG) provided on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care evaluation and management (E&M) visit
(99291) provided on June 13, 2021.
You asked the Plan to pay for critical care visit. You say that the documentation supports the service billed.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because code
99291 has a Medically Unlike Edit (MUE) value of 1 however you billed 2 units. The Plan also says that they
paid 1 unit of code 99291 so this second unit is not payable.
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 99291 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. The Plan paid for 1 unit of this code. Based on this information, we decided that
Medicare rules for coverage of critical care visit have not been met. Therefore, we decided that the Plan does
not have to pay for a critical care evaluation and management (E&M) visit (99291) provided on June 13, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast biopsy (19083) provided on August 6, 2021.

You asked the Plan to pay for the breast biopsy (19083. You say that 19083 was performed bilateral due to a
mass on the right and left breast. The Plan denied your request. The Plan says 2 billed units of code 19083 
exceeds the allowable amount.

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 19083 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. One unit should have been billed with a modifier indicating a bilateral procedure. 
Based on this information, we decided that Medicare rules for coverage of the breast biopsy (19083 have not 
been met. Therefore, we decided that the Plan does not have to pay for the breast biopsy (19083) provided on 
August 6, 2021.