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

 We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on August 21, 2021.  You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  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 70450 is a column II code to column I code 70496. 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 a computed tomography scan (70450) provided on August 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 25, 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 procedure code 76705 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment.       Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on July 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you would like the medical records reviewed and the claim to be reprocessed and paid. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 20, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 27, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hemoglobin testing (85018) provided on June 16, 2021.
You asked the Plan to pay for hemoglobin testing. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.
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 85018 is a column II code to column I code 85025. 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 hemoglobin testing (85018) provided on June 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pre-approve skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there are no identifiable daily skilled nursing needs.  There are no identifiable daily skilled rehabilitation needs. Your condition does not meet severity of illness or intensity of service criteria for continued facility stay. Medicare coverage criteria are not met.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 5, 2021 and May 19, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the lab services were performed for end-stage renal disease (ESRD). Payment for these services is included in payment to the ESRD facility. 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 laboratory services rendered on May 5, 2021 and May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone replacement grafts - retained natural tooth - first site in quadrant (D4263) provided September 1, 2021, to October 13, 2021.  You asked the Plan to pay for the bone replacement grafts. You say that you had contacted the Plan about coverage prior to the services being rendered. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement grafts - retained natural tooth - first site in quadrant (D4263) provided September 1, 2021, to October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Vertiflex procedure (22869) provided on October 8, 2020.  You asked the Plan to pay for a Vertiflex procedure. You say that the requested treatment was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested treatment is experimental/investigational.  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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that two learned orthopedic societies have not endorsed the use of the procedure at issue. The procedure is considered experimental/investigational.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pay for a Vertiflex procedure (22869) provided on October 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on June 7, 2021.  You asked the Plan to pay for a supply allowance for a continuous glucose monitor. You say that the item at issue was a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a supply allowance for a continuous glucose monitor (K0553) provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of an impacted tooth, completely bony (D7240), and therapeutic parenteral drug (D9610) provided on April 19, 2021.  You asked the Plan to pay for the dental services. You say that you were advised that you would only have to pay $47 out of pocket for the services. You say that you were advised insurance would pay the rest. You also say that you received a bill for $450. The Plan denied your request. The Plan says removal of an impacted tooth is not listed as a covered service. The Plan says that therapeutic parenteral drug is not listed as a covered service either.  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 removal of an impacted tooth, and therapeutic parenteral drug are not among those covered under this benefit. Additionally, the record shows that the treatment plan that you signed on March 19, 2021, states that it is not a binding contract, and you accept all charges not covered by insurance. Therefore, we decided that the Plan does not have to pay for the removal of an impacted tooth, completely bony (D7240), and therapeutic parenteral drug (D9610) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 3, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage related disease (ESRD) and payment is included in payment to the facility.     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 laboratory services rendered on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology consultation rendered on September 22, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 80500 (lab pathology consultation) and G0452 (molecular pathology procedure, physician interpretation and report). Code 80500 is a column II code with a modifier indicator of 1 when billed with column I code G0452. Code 80500 was not billed with an appropriate modifier to allow for separate payment.      Therefore, we decided that the Plan does not have to pay for the pathology consultation rendered on September 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the immediate dentures (D5130, D5140), extractions (D7210 x 15), bone replacement grafts (D7953 x 3), and alveoloplasty in conjunction with extractions (D7310 x 4) provided from July 22, 2021, to August 2, 2021.  You asked the Plan to reimburse you for the dental services. You say that you needed this surgery due to past cancer radiation treatments. You also say that you paid $7,000 out of pocket. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services received out of network are not covered.  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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the immediate dentures (D5130, D5140), extractions (D7210 x 15), bone replacement grafts (D7953 x 3), and alveoloplasty in conjunction with extractions (D7310 x 4) provided from July 22, 2021, to August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for THE laboratory work provided on August 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that your doctor wanted a rapid return of your blood work. You say you went to the out-of-network laboratory to get the results quickly. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on August 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for dialysis treatments provided from April 2, 2021, to April 30, 2021.  You asked the Plan to waive the coinsurance for the dialysis treatments. You say that you have already paid your April statement balance and you received another bill for $100. The Plan denied your request. The Plan says the correct coinsurance was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient dialysis treatments.   The file shows that you had a total of 9 dialysis treatments from April 2, 2021, to April 30, 2021. You have been asked to pay $68.87 for each treatment, which is 20% of the allowed amount for the dialysis treatments ($344.36 allowed amount x 20% coinsurance = $68.87). The total for all 9 treatments is $619.83 ($68.87 coinsurance x 9 treatments = $619.83). The dialysis treatments falls within the Services to Treat Kidney Disease 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 coinsurance for dialysis treatments provided from April 2, 2021, to April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on August 17, 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 there is no valid physician order.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.   We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month (A4595) provided June 1, 2021.  You asked the Plan to pay for electrical stimulator supplies. You say that you are in disagreement with this decision as you have submitted the order, records and delivery ticket which show the delivery of the should brace was received by the enrollee and the supplies are medically necessary. The Plan denied your request. The Plan says the documentation provided does not include one or more required records to support payment for this service. Payment is not allowed because it contains duplicate charges or inappropriate number of units.  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 A4595 is electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes).  We find that CPT code A4595 x24 units is not supported in the medical record. Specifically, the record does not contain a valid proof of delivery for the supplies provided in this case. There is a wrong date of service and invalid shipping confirmation. The order also exceeds the utilization guidelines. Based on this information, we decided that Medicare rules for coverage of electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies, 2 lead, per month (A4595) provided June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a fluciclovine (contrast agent) injection provided on August 19, 2021.  You asked the Plan to waive the coinsurance for the contrast agent. You say that you feel that you should only have a $25 copayment for the PET scan. The Plan denied your request. The Plan says the correct coinsurance was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for medical supplies, including chemical agents used in certain diagnostic procedures.     You have been asked to pay $550.96, which is less than 20% of the allowed amount for the contrast agent ($4924.80 allowed amount x 20% coinsurance = $984.96). The file shows that your maximum out-of-pocket was met during this visit, therefore you are only responsible for the reduced charge instead of the full 20% coinsurance. The contrast agent 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 coinsurance for a fluciclovine (contrast agent) injection provided on August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap (A9273) purchased April 7, 2021 to June 15, 2021 from an out of network provider.  You asked the Plan to pay for the hot water bottle, ice cap or collar any type. You say that this is a standard service provided for patients undergoing chemotherapy. You do not understand the reason for the denial of these reimbursement claims. The Plan denied your request. The Plan says this item is not considered primarily a medical service.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap (A9273) purchased April 7, 2021 to June 15, 2021 from an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on March 31, 2021.  You asked the Plan to pay for an electrocardiogram. You say that this is separately payable. The Plan denied your request. The Plan says this is included in other procedures.  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 93010 is a column II code to column I code 33967. 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 an electrocardiogram (93010) provided on March 31, 2021.