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

We decided that the Plan does not have to waive the copayment for the surgery you had to fix a broken arm on August 21, 2021.

You asked the Plan to waive the copayment for the outpatient surgery. You say that you do not want to pay the bill until you get an itemized invoice from the hospital. You said this was emergency surgery, so you had no opportunity to seek out a cheaper alternative. The Plan denied your request. The Plan says you were charged this copayment 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 $325 copayment for outpatient hospital services. 

You have been asked to pay a $325 copayment for the outpatient surgery. The outpatient surgery falls within the outpatient hospital 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 surgery you had to fix a broken arm on August 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and pay for the provisional splinting (D4321) provided on June 30, 2021.

You asked the Plan to waive the deductible and pay for the dental service. You say that it was the enrollee's understanding that the plan covered dental procedures as required to maintain healthy dental health. You say that it was the enrollee's understanding that the plan paid 50% for dental services. You say that the enrollee learned of the $25 deductible the same day the denial was received.

You also say that you have no policy to review, and changes have not been communicated. The Plan denied your request. The Plan says there is a $25 deductible per person, per calendar year, on all services except cleanings, exams, and bitewing x-rays. The Plan also says provisional splinting is not listed as a covered 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 provisional splinting is not among those covered under this benefit. Additionally, the deductible is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the deductible or pay for the provisional splinting (D4321) provided on June 30, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) represented by code 37253 provided on February 25, 2021.

You asked the Plan to pay for code 37253. You say that the medical records support the billing of code 37253 provided on February 25, 2021. The Plan denied your request. The Plan says that the medical records do not support the billing of code 37253 provided on February 25, 2021.

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 37253 is Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure). 

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 code 37253. Our reviewer says that the medical records support the billing of code 37253 provided on February 25, 2021. Our reviewer found code 37253 may be reported for each additional vessel studied during a vascular procedure. There is documentation of an intravascular ultrasound (noncoronary vessel) being performed during a diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; for each additional noncoronary vessel. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 37253 have been met. Therefore, we decided that the Plan has to pay for the Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) represented by code 37253 provided on February 25, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for selective catheter placement (36246-59) and angiography (75736-59) provided on January 26, 2021.

You asked the Plan to pay for 36246-59 and 75736-59. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these codes are inclusive to the primary procedure codes of 36427 and 37244.

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 36246 is selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family. The CPT Code Manual definition of code 75736 is angiography, pelvic, selective or supraselective, radiological supervision and interpretation.

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 36246-59 and 75736-59. Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found the records reflect procedure 36247 also being performed on the same date of service as 36246 by the same physician. The records provided do not include sufficient documentation to verify that 36246 was performed as a distinct, separate service from procedure 36247, therefore the payment for this service is included in reimbursement for 36247 and no additional payment is due as 36246-59 cannot be verified. Code 75736 is inclusive to procedure 37244. The records provided do not include sufficient documentation to validate that 75736 was performed as a distinct, separate service from 37244, therefore 75736-59 (2 units) cannot be verified and is not eligible for separate reimbursement. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 36246-59 and 75736-59 have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement (36246-59) and angiography (75736-59) provided on January 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the myocardial perfusion imaging, tomographic (SPECT) multiple studies (78452), radioactive material for scan, diagnostic, per study dose (A9500), Regadenoson injection (J2785), and cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report (93015) provided May 12, 2021.
You asked the Plan to waive the cost shares for the cardiac nuclear study, radioactive material for scan, Regadenoson injection and cardiovascular stress test. You say that you were not informed there would be a cost
beyond your specialists visit copayment. The Plan denied your request. The Plan says the cost sharing 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 20% coinsurance for each nuclear medicine study or imaging and for Medicare-covered Part B drugs. You have been asked to pay $90.82 for the cardiac nuclear study and $47.45 for the radioactive material for scan, Regadenoson injection and cardiovascular stress test. The cardiac nuclear study falls in the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The Regadenoson injection for the stress test falls within the Medicare Part B Drugs benefit category. This means that you have been asked to pay less than or equal to 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 cost shares for the myocardial perfusion imaging, tomographic (SPECT) multiple studies (78452), radioactive material for scan, diagnostic, per study dose (A9500), Regadenoson injection (J2785), and cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report (93015) provided May 12, 2021.
Your complaint about being charged separate cost-sharing for the services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on May 17, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that you want to know why this wasn't
paid under your $240 allowance. The Plan denied your request. The Plan says the deductible applied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a $100 deductible per
calendar year that had not been met at the time the periodontal maintenance was received. Therefore, we
decided that the Plan does not have to pay for the periodontal maintenance provided on May 17, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for congestive heart failure and kidney failure. Medical problems are stable. There are no complex
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the compression stockings
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 10, 2021.

You asked the Plan to waive the copayment for laboratory services. You say that due to matters beyond your control, your lab work was done on a different day than your wellness visit. 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 $10 copayment for laboratory tests that are not FIT (fecal immunochemical test) tests. 

You have been asked to pay a $10 copayment for laboratory services. Laboratory services falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Regardless of the day on which the laboratory services are provided, they are not included in a wellness visit and are subject to a separate copayment. 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 laboratory services provided on May 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI)
scan of any joint of the lower extremity; without contrast material (73721) provided on May 3, 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 $150
copayment for advanced radiology services.

You have been asked to pay a $138.23 copayment for the advanced radiology service provided. This is the
Plan's allowed amount for this service, which is less than the applicable copayment. 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 magnetic resonance imaging (MRI) scan of any joint of the lower extremity;
without contrast material (73721) provided on May 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the abdomen (74019) rendered by the out-of-network (OON) provider on May 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the abdomen (74019) rendered by the out-of-network (OON) provider on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Destruction (e.g., laser surgery, electrosurgery,
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion
represented by code 17000, the Strapping; ankle and/or foot represented by code 29540, and the Application of
a modality to 1 or more areas; whirlpool represented by code 97022 provided on October 28, 2020.
You asked the Plan to pay for codes 17000, 29540, and 97022. You say that the medical records support the
billing of codes 17000, 29540, and 97022 provided on October 28, 2020. The Plan denied your request. The
Plan says the medical records do not support the billing of codes 17000, 29540, and 97022 provided on
October 28, 2020.
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 17000 is Destruction (e.g., laser surgery, electrosurgery,
cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion.
The definition of code 29540 is Strapping; ankle and/or foot. The definition of code 97022 is Application of a
modality to 1 or more areas; whirlpool.
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 codes 17000, 29540, and 97022. Our reviewer says that the
medical records do not support the billing of codes 17000, 29540, and 97022 provided on October 28, 2020.
Our reviewer found after careful review of the enclosed information and the pertinent guidelines for this case,
the medical records do not support the billing of codes 17000, 29540 or 97022. First and foremost, there is no
documentation advising of a premalignant lesion to the plantar aspect of the left or right foot. The only mention
of the lesion is a callous to the plantar feet. The code 17000 is not appropriate for debridement of a callous.
Although the biomechanics of the feet are described in detail, there is no mention of Whirlpool performed on
this enrollee's feet, or any strapping placed in this enrollee's feet. Therefore, the medical records do not support
the billing of codes 17000, 29540 or 97022.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of codes 17000, 29540, and 97022 have not been met. Therefore, we decided that
the Plan does not have to pay for the Destruction (e.g., laser surgery, electrosurgery, cryosurgery,
chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion represented by
code 17000, the Strapping; ankle and/or foot represented by code 29540, and the Application of a modality to 1
or more areas; whirlpool represented by code 97022 provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap provided on January 19, 2021.
You asked the Plan to pay for muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) (15733). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the operative report did not include documentation of this procedure.
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 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 muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) (15733). Our reviewer says that the procedure code billed to the Plan does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) was performed on January 19, 2021, therefore this service 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 muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) (15733) have not been met. Therefore, we decided that the Plan does not have to pay for muscle, myocutaneous, or fasciocutaneous flap provided on January 19, 2021.