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

 We decided that the Plan does not have to pay for ultrasounds (76700, 76770) provided on February 9, 2021.  

You asked the Plan to pay for ultrasounds. You say that these codes are supported. The Plan denied your request. The Plan says the records document limited ultrasounds rather than complete. 
 
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 76700 is ultrasound, abdominal, real time with image documentation; complete. The definition of 76770 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete.  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for ultrasounds. Our reviewer says that these codes are not supported. Our reviewer found a complete abdominal ultrasound consists of real time scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, abdominal aorta, inferior vena cava, including any abdominal abnormality. The documentation supports a limited abdominal ultrasound.  complete retroperitoneal ultrasound consists of scans of kidneys, abdominal aorta, common iliac artery origins and inferior vena cava, including retroperitoneal abnormality.  In this case, common iliac artery origins and inferior vena cava are not documented in the report, and cannot be verified.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasounds have not been met. Therefore, we decided that the Plan does not have to pay for ultrasounds (76700, 76770) provided on February 9, 2021
.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the nasal endoscopy (31231), provided on July 19, 2021.  

You asked the Plan to waive the copayment for the nasal endoscopy. You say that there should not be a copayment. The Plan denied your request. The Plan says the cost share was applied 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 $100 copayment for outpatient surgery and other medical services provided at hosiptal outpatient facilities and ambulatory surgical centers.   

You have been asked to pay a $100 copayment for the nasal endoscopy. This service falls within the outpatient surgery and other medical services provided at hosiptal outpatient facilities and ambulatory surgical centers 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 nasal endoscopy (31231), provided on July 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0127), provided on August 12, 2021 and August 17, 2021.

You asked the Plan to waive the copayment for the ambulance service. You say that you cannot afford the cost share. The Plan denied your request. The Plan says the cost share was applied 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 $325 per trip for Medicare-covered ambulance services for ambulance services. 

You have been asked to pay $325 per trip for Medicare-covered ambulance services for the ambulance service. This service falls within the ambulance 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 ambulance service (A0127), provided on August 12, 2021 and August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70544) provided to the enrollee on August 16, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says 70551 and 70554 should not be billed together on the same date of 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 70554 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 70544) provided to the enrollee on August 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on July 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for psychotherapy services. You say that the most medically necessary and appropriate way to help the enrollee was to perform psychotherapy to assess the enrollee's current state of health and help create a proper course of treatment. 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 individual psychotherapy services (90832) provided on July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on May 10, 2021.  

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that in February 2020 you had an evaluation of dental work to be done and were informed that a claim was filed, and the provider was paid. You also say that You went there because the evaluation was supposed to be free, and you would like your current dentist to be paid for these services. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitations have been exceeded. 

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, comprehensive oral evaluation (D0150) and is limited to one procedure code every three years, and complete series of intraoral x-rays (D0210) is limited to one procedure code every five years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on February 28, 2020 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 
 
 Our physician reviewer found based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 

 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0480, G0483) rendered by the out-of-network (OON) provider on June 11, 2021 and June 25, 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 drug testing services (G0480, G0483) rendered by the out-of-network (OON) provider on June 11, 2021 and June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic CT scan of the chest (71250) performed on February 23, 2021.  

You asked the Plan to waive the copayment for the diagnostic CT scan. You say that the services should be covered as they were due to a previous surgery. The Plan denied your request. The Plan says the cost-sharing applied is correct based on the services 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 $250 copayment for Outpatient diagnostic tests and therapeutic services and supplies.     

You have been asked to pay a $250 copayment for a diagnostic CT scan. CT scans 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 copayment for a diagnostic CT scan of the chest (71250) performed on February 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on November 17, 2020.

You asked the Plan to pay for the air transport and mileage. You say that Medicare does not require precertification or prior authorization when the services are urgent or emergent. You also say that the enrollee required immediate transfer to a higher-level care facility with the necessary neurology services which were unavailable at the sending facility or closer. The Plan denied your request. The Plan says these services were not medically necessary.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 

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 air transport and mileage. Our reviewer says that the fixed wing air transport was not medically reasonable and necessary. Our physician reviewer found the documentation does support that the patient suffers from an illness or injury that contraindicates transportation by any means other than ambulance. Our reviewer found that the documentation does not support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. In the emergency department he was cleared to transport via ground ambulance and remained stable. Our physician reviewer also found that the documentation did support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. 

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 air transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the fixed wing air transport (A0430) and fixed wing air mileage (A0435) provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80061, 36415, 80050, and 83036) provided to the enrollee on June 18, 2021, by an out-of-network provider.  

You asked the Plan to pay for the laboratory services. You say that you do not want the provider to charge you for the $11.00 write off amount. The Plan denied your request. The Plan says the provider is out-of-network and can balance bill for amounts not paid by insurance.  

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 laboratory services have not been met. The rules governing balance billing as well as the rules governing the MA payment of MA-plan contracting providers, non-contracting providers and original Medicare participating and non-participating providers are listed below by type of provider. For a Non-contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the enrollee. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80061, 36415, 80050, and 83036) provided to the enrollee on June 18, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 26, 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 must 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 out of network physician services provided to the enrollee on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI scan of an arm joint (73221) provided on July 6, 2021.  You asked the Plan to waive the copayment for an MRI scan of an arm joint. You say that you were not informed that you had a copayment. 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 $225 copayment for Medicare-covered diagnostic radiology services, not including X-rays, mammography, or ultrasounds.   You have been asked to pay a $225 copayment for an MRI scan of an arm joint. An MRI scan of an arm joint 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 MRI scan of an arm joint (73221) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodontal scalings and root planings (D4342) provided on September 2, 2021.

You asked the Plan to pay more for the scalings and planings. You say that your dental provider advised that these services would be covered. You also say that you moved, and your allowance changed from $1,000 to $500, and you were not aware of this change. The Plan denied your request. The Plan says your full dental allowance of $500 was paid and the remaining balance of $512 is your liability due to this amount being beyond your annual dental allowance amount. The Plan also says that you contacted the Plan on August 27, 2021 to change plans due to changing locations and this Plan became effective as of September 1, 2021.

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 offers a $500 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the September 2, 2021 date of service and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay more for the periodontal scalings and root planings (D4342) provided on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a joint injection provided on May 27, 2021.  You asked the Plan to waive the copayment for the injection. You say that you were not in an operating room, and you only had a cortisone shot. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $450 copayment for outpatient surgical procedures.   You have been asked to pay $379.91, which is less than the $450 copayment for the injection. Please note that joint injections are considered surgical procedures. The injection falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a joint injection provided on May 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services rendered on December 17, 2020.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95957, 95908, and 95885 is 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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).  

We find that CPT codes 95957, 95908, and 95885 are not supported in the medical record. Specifically, there is no documentation of digital analysis of an EEG for epileptic spike analysis to support code 95957. There is no documentation of 3-4 nerve conduction studies to support code 9590. There is no documentation of needle electromyography to support code 95885. 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 testing services rendered on December 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolonged services (99354) provided on July 14, 2021.  

You asked the Plan to pay for the prolonged services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT code 99354 and 90833.  

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 99354 is a column II code to column I code 90833. The edit does not allow for the use of a modifier so the services represented by this code pair are not separately payable. 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 prolonged services (99354) provided on July 14, 2021.