Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to change the deductible to a copayment for an outpatient mental health telehealth visit (99213) rendered on September 28, 2021.  You asked the Plan to change the deductible to a copayment for an outpatient mental health telehealth visit. You say that you were not aware that the bill was going to be put through your deductible and you thought it was going to be through the copayment. You also ask the Plan to overturn the deductible to the copayment. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that that your deductible is $750. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services.  Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the calendar year. The Plan deductible applies to an outpatient mental health telehealth visit. Your contract with the Plan also says that there is a $30 copayment after the deductible is met for each telehealth outpatient mental health or outpatient psychiatric individual therapy visit.   You have been asked to pay $84 toward the $750 deductible for an outpatient mental health care telehealth visit. The item or service you asked the Plan to change the deductible to a copayment for falls within the benefit category outpatient mental health care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient mental health care. The deductible is a contractual obligation that had not been met at the time an outpatient mental health telehealth visit was received on September 28, 2021. Therefore, we decided that the Plan does not have to change the deductible to a copayment for an outpatient mental health telehealth visit (99213) rendered on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on May 13, 2021.  You asked the Plan to pay for the advance care planning services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.  We find that CPT code 99497 is not supported in the medical record. Specifically, the submitted medical records do not include sufficient information to support the performance of Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. The documentation states less than 15 minutes was spent on this discussion. This means the documented time is insufficient to support this code. Based on this information, we decided that Medicare rules for coverage of the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intra-articular facet joint steroid injections.  You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications established in the applicable LCD.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injections. Our reviewer says that the requested intra-articular facet joint steroid injections are not medically reasonable and necessary. Our physician reviewer found that the algorithm for facet mediated pain does not include therapeutic steroid intra-articular facet injection, Therefore, the request is deemed not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve intra-articular facet joint steroid injections.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve a replacement oral device/appliance (E0486).  You asked the Plan to pre-approve an oral device/appliance. You say that this device is necessary because the enrollee has altered breathing during sleep and this device is useful. The Plan denied your request. The Plan says that the records do not support medical necessity for the requested oral device.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   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 an oral device/appliance. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has obstructive sleep apnea (OSA) who had been using an oral appliance since 2017. However, it was reported that it was broken and beyond repair. He had received measurable benefit from this device such as no apnea or snoring. Based on the provided documentation, which supports ongoing use of the device to control the enrollee's OSA, a replacement is reasonable and medically necessary as his current device is broken according to the recent 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 an oral device/appliance have been met. Therefore, we decided that the Plan has to pre-approve a replacement oral device/appliance (E0486).   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 pay for acupuncture (97810, 97811) provided on October 7, 2021.  You asked the Plan to pay for acupuncture. You say that this is supported in the records. The Plan denied your request. The Plan says this was not provided by a provider that participates in Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for acupuncture (97810, 97811) provided on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on April 27, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing services must be obtained through our contracted vendor, Nations Hearing, to receive in-network benefits.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the hearing aids were not obtained through the Plans contracted vendor. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the office visits (99203, 99213) provided on July 22, 2021 and July 30, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $50 copayment for urgently needed services provided in an Urgent Care Center.   You have been asked to pay $100 ($50 copayment x 2) for the urgent care visits 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 copayments for the office visits (99203, 99213) provided on July 22, 2021 and July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the specialist office visits, the Part B drug, and the x-ray provided from June 30, 2021, to August 5, 2021.  You asked the Plan to waive the copayments for the specialist office visits, a Part B drug, and the x-ray. You say that the balance is supposed to be paid by the insurance plan. 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 for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office, 20% coinsurance for each Medicare-covered Part B drug, and a $15 copayment for each Medicare-covered standard x-ray service.   You have been asked to pay $107.15 for the specialist office visits, a Part B drug, and the x-ray. The specialist office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The Part B drug falls within the "Medicare Part B Prescription Drugs" benefit category. The x-ray falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart below.  Date of Service Service Allowed Amount Copayment/ Coinsurance Member Liability June 30, 2021 X-ray $28.51 $15 $15 July 28, 2021 Specialist office visit $87.48 $45 $45 July 28, 2021 Part B drug $10.74 20% $2.15 August 5, 2021 Specialist office visit $87.48 $45 $45 Total    $107.15  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 the specialist office visits, the Part B drug, and the x-ray provided from June 30, 2021, to August 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided on May 14, 2021.  

You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided on May 14, 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.  

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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on October 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. 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 member was referred by a non-participating provider. The Plan also says that the referral was not authorized by attending physician.  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 an office visit (99214) provided on October 29, 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 mechanical traction therapy (97012) and electrical stimulation (G0283) provided on August 2, 2021.  You asked the Plan to pay for the mechanical traction therapy and electrical stimulation. You say that this claim should be reprocessed based on agreements in place. The Plan denied your request. The Plan says the only service covered when rendered by a chiropractor is the manual manipulation of the spine to correct subluxation.  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 the mechanical traction therapy (97012) and electrical stimulation (G0283) provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) coded 99072 provided on September 15, 2021.  You asked the Plan to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s). 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. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, this code has a status code of "B". This means that payment for covered services is always bundled into payment for other services not specified. The provider billed and was paid for the bundled services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) coded 99072 provided on September 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the enrollee from April 15, 2021, through April 22, 2021.  

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered 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.  

CPT code 99601 has a status code "I", which means it is not valid for Medicare purposes. As the claim was billed with a CPT code which is invalid for usage with Medicare; we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. 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 the home infusion/specialty drug administration, per visit (up to 2 hours) (CPT code 99601) provided to the enrollee from April 15, 2021, through April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on May 13, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered 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.  CPT code(s): S1015 and S8301, have a status code "I", which means it is not valid for Medicare purposes. As the claim was billed with a CPT code which is invalid for usage with Medicare; we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. 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 the intravenous (IV) tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on May 13, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided from August 4, 2021, to August 5, 2021.  

You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. You say you had an x-ray and electrocardiogram, but you did not see a doctor.   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 $120 copayment for each emergency room visit.    

You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows services were rendered during the emergency room visit. 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 emergency room visit provided from August 4, 2021, to August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 16, 2021.  You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order or signed laboratory requisition for the billed test; therefore, the services cannot be verified.    Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on June 16, 2021.