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

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) provided on August 19, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for acupuncture services. You say that you are requesting reimbursement of $175.00 for the acupuncture services. 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. Acupuncture is only covered for the treatment of chronic low back pain.

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 acupuncture, initial 15 minutes (97810) provided on August 19, 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 shock wave therapy (99213, 11042) provided January 6, 2021.

You asked the Plan to pay for the shock wave therapy. You say that the procedure was medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.

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 shock wave therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has diabetic foot ulcers. There is insufficient literature to demonstrate the safety and effectiveness of the requested service for the enrollee's specific condition.

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 shock wave therapy have not been met. Therefore, we decided that the Plan does not have to pay for shock wave therapy (99213, 11042) provided January 6, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an MRI scan of an arm joint (73221) provided on April 16, 2021, by an 
out-of-network provider.

You asked the Plan to pay for an MRI scan of an arm joint. You say that the Plan authorized the procedure at 
issue. The Plan denied your request. The Plan says that rules for out-of-network care have not been met.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The case record shows that the Plan was informed that the procedure at issue 
would be provided out-of-network and did not issue a denial. The case record documents that the Plan provided 
a confirmation of the scheduling including the confirmation date range. We find that this constitutes an 
approval for the service at issue. The case record does not substantiate the Plan's decision to issue a denial.
Therefore, we decided that the Plan has to pay for an MRI scan of an arm joint (73221) provided on April 16, 
2021, by an out-of-network provider.

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 a domiciliary or rest home visit with a physician (99336) 
provided on July 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for a domiciliary or rest home visit with a physician. You say that it is the nursing 
facility's responsibility to get authorizations for their patients. 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 are 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 with a physician 
(99336) provided on July 26, 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 surgical extractions (D7210), immediate dentures (D5130, D5140), and unspecified removable prosthodontic procedures (D5899) provided on July 27, 2021.

You asked the Plan to pay for the dental services. You say that you need additional dental care and help paying for this bill. The Plan denied your request. The Plan says dentures and unspecified removable prosthodontic procedures are not covered services under your dental benefit. In addition, you have exhausted your $1,000 annual maximum allowance for supplemental dental care and are responsible for any remaining charges above this allowance.

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. The Plan does not cover
services that are not listed in the dental benefits chart. There is an annual maximum allowance of $1,000 for supplemental dental care. After the annual maximum is exhausted, any remaining charges are your responsibility. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the immediate dentures and unspecified removable prosthodontic procedures are not among those covered under this benefit. In addition, documentation shows that on the date in question, you met and exceeded your $1,000 annual maximum for covered dental care. Therefore, we decided that the Plan does not have to pay any additional amount for the surgical extractions (D7210), immediate dentures (D5130, D5140), and unspecified removable prosthodontic procedures (D5899) provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on October 14, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each specialist visit for Medicare-covered services. 

You have been asked to pay a $30 copayment for the Medicare-covered specialist visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit (99213) provided on
October 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided August 26, 2021.

You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that you were never informed that if a small non-cancerous polyp was found during the procedure, you would be responsible for a $290 copayment. The Plan denied your request. The Plan says the copayment 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 $290 copayment for Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $290 copayment for the colonoscopy with biopsy. The colonoscopy with biopsy falls within the Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Your screening colonoscopy became a diagnostic colonoscopy during the procedure as explained in the Plan's Evidence of Coverage. 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 colonoscopy, flexible; with biopsy, single or multiple (45380) provided August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on August 12, 2021.

You asked the Plan to pay for the services provided. You say that the services were medically necessary for the 
enrollee. The Plan denied your request. The Plan says the provider did not bill as required by coding 
regulations.

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 14001 is adjacent tissue transfer or rearrangement, trunk; 
defect 10.1 sq cm to 30.0 sq cm. We find that CPT code 14001 is a surgical closure procedure. The breast 
procedure the enrollee received includes incision and closure. Based on this information, we decided that 
Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgery services provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided from March 15, 2021, to April 20, 2021.
You asked the Plan to pay for psychotherapy services. You say that this was medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that unless the beneficiary's primary care or attending physician has referred the beneficiary to the clinical social worker, a clinical social worker must agree to inform the beneficiary that it is desirable for the clinical psychologist to consult with the beneficiary's attending or primary care physician (if the beneficiary has such a physician) to consider any conditions contributing to the beneficiary's symptoms. We looked at the file and Medicare rules. Neither the records nor the claims for these services show that the enrollee was referred by her primary care physician. The records also do not document that the enrollee was informed that it is desirable for the clinical psychologist to consult with her physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met.
Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided from March 15, 2021, to April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for intermediate wound repair of face (12052) provided on August 23, 2021.

You asked the Plan to waive the copayment for intermediate wound repair of face. You say that it would be difficult for you to pay this 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 $150 copayment for outpatient procedures and services and outpatient surgery (not including Medicare-covered colonoscopies).

You have been asked to pay a $150 copayment for intermediate wound repair of face. Intermediate wound repair of face 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 intermediate wound repair of face (12052) provided on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation(s) services coded 93296 provided on
You asked the Plan to pay for the interrogation device evaluation(s) 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. In this case, the CPT Code Manual definition of code 93296 is interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system, leadless pacemaker system, or implantable defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results.
We find that CPT code 93296 is not supported in the medical record. Specifically, this code has a Professional Component (PC)/Technical Component (TC) Indicator of 3. This means this code is a technical component only code. Based on this information, we decided that Medicare rules for coverage of the interrogation device evaluation(s) services have not been met. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation(s) services coded 93296 provided on
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on July 12, 2021.
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you feel that you should not have to pay this copayment as the appointment only lasted 10 minutes. 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 $35 copayment for specialist telehealth visits. You have been asked to pay a $35 copayment for the specialist telehealth visit. Specialist telehealth visits 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 a specialist telehealth visit provided on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided July 19, 2021, to July 21, 2021.

You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that the copayment is a financial burden, and it was a surprise. The Plan denied your request. The Plan says the copayment 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 $275 copayment per day for days 1-5 for Inpatient hospital care.

You have been asked to pay a total of $550 ($275 copayment x 2 days = $550) for the inpatient hospital admission and services. The inpatient hospital admission and services fall within the Inpatient hospital care 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 inpatient hospital admission and services provided July 19, 2021, to July 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the air ambulance services provided on May 29, 2021.  

You asked the Plan to pay for the air ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 ambulance services. Our reviewer says that the documentation does not support that the air ambulance services were medically reasonable or necessary. Our physician reviewer found the enrollee had a hip fracture and was transported via air transport to a different hospital for orthopedic surgeon consultation. The enrollee was hemodynamically stable with normal vitals prior to transportation. Transportation via ground only would have only taken 33 minutes vs 16 minutes via air. The documentation does not support that the enrollee's condition was such that the time needed to transport an enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Ground transportation would have been completed in a reasonable time frame, and the enrollee was not in critical condition with vitals being normal. Therefore, the enrollee did not meet criteria for the services rendered.  

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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance services provided on May 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on May 29, 2021 to May 31, 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 billed correctly.

The Plan must follow Medicare rules. The rules say that Medicare requires all home health agency billing claims to be submitted on the Form CMS-1450/UB-04 hard copy form. 

We looked at the file and Medicare rules. The file shows that the claims were not billed on the required CMS-1450/UB-04 form. Therefore, we decided that the Plan does not have to pay for the home health services rendered on May 29, 2021 to May 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (29822, 29825) provided August 23, 2021.  You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed codes share a bundled relationship with another code 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. In this case, we have confirmed that codes 29822 & 29825 are column II codes to column I code 29824. 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 surgical services (29822, 29825) provided August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the lumbar spine provided on September 16, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you do not feel that the copayment is fair. 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 $250 copayment for diagnostic radiology services that are not ultrasounds.   You have been asked to pay a $250 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the lumbar spine provided on September 16, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on August 17, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 for each Medicare-covered emergency room visit.   

You have been asked to pay $110 for the Medicare-covered emergency room visit provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on August 17, 2021.