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

We decided that the Plan does not have to pay for the psychotherapy (90834) rendered by the out-of-network (OON) provider from March 20, 2021, through May 22, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90834) rendered by the out-of-network (OON) provider from March 20, 2021, through May 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood oxygen level measurement provided on December 10, 2019.

You asked the Plan to pay for the blood oxygen level measurement. You say that the medical records to process the claim toward payment are attached. The Plan denied your request. The Plan says this service is always bundled into another payable physician service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 94761 is noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise).

We find that CPT code 94761 is not supported in the medical record. Specifically, Per the Physician Fee Schedule, CPT code 94761 has a status indicator of T. This means that CPT code 94761 is only paid when there are no other services payable under the Physician Fee Schedule billed on the same date by the same provider. This claim was billed with another payable code on the same date by the same provider. Based on this information, we decided that Medicare rules for coverage of the blood oxygen level measurement have not been met. Therefore, we decided that the Plan does not have to pay for the blood oxygen level measurement provided on December 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case if you are able to cooperate with therapy in the future. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on June 21, 2021.

You asked the Plan to pay for the SelectMDx testing (81479). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Medicare specifically excludes coverage of code 81479 when used for SelectMDx testing. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing (81479) provided on June 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85060, 85097, 88305, 88311, 88313, 88341, 88342, 88360, 88377) provided May 20, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 

We looked at the file and Medicare rules. The documentation does not include a signed physician order by the physician that is treating the enrollee. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (85060, 85097, 88305, 88311, 88313, 88341, 88342, 88360, 88377) provided May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, spine, cervical; two or three views (72040) provided February 19, 2020.
You asked the Plan to pay for the diagnostic service. You say that it is company policy to bill the auto insurance first when an accident occurs. Please review the supporting documentation and re-process procedure codes 72040 26 accordingly and waive the timely filing denial. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the diagnostic service was not filed until May 28, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the radiologic examination, spine, cervical; two or three views (72040) provided February 19, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 3, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 0242U (1 Unit) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 0242U is "Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements." 

We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on May 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 23, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you feel that the emergency care was unnecessary. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. 

The enrollee has been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the self-administered drugs provided on April 22, 2021, and April 23, 2021.

You asked the Plan to pre-approve the self-administered drugs. You say that you would like to appeal this service. The Plan denied your request. The Plan says self-administered drugs are not covered while you are inpatient.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the self-administered drugs provided on April 22, 2021, and April 23, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the CGM supplies provided from January 28, 2020, to March 3, 2021.

You asked the Plan to waive the deductible for the CGM supplies. You say that you were told the durable medical equipment supplies were covered at 100% and the deductible would not be applied. 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. Your contract with the Plan says that there is a $350 deductible which applies to coinsurance at an out-of-network durable medical equipment provider.

The CGM supplies you asked the Plan to waive the deductible for falls within the "Durable medical equipment (DME) and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $350 deductible which applies to coinsurance at an out-of-network durable medical equipment provider. This cost sharing is a contractual obligation that had not been met at the time the CGM supplies was received on January 28, 2020, to March 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the CGM supplies provided from January 28, 2020, to March 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an echocardiograph provided on July 23, 2021.

You asked the Plan to waive the copayment for an echocardiograph. You say that the Plan normally pays for this service and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $100 copayment for outpatient diagnostic tests provided in an outpatient hospital facility. 

The record shows that you received an echocardiograph at an outpatient hospital facility on July 23, 2021. Therefore, you are responsible to pay the $100 copayment. 

You have been asked to pay a $100 copayment for an echocardiograph. An echocardiograph falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an echocardiograph provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 7, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Additionally, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental services provided on August 2, 2021.
You asked the Plan to pay for the dental services. You say that this was the only local surgeon that as able to get you in the same day as this was an emergency decision. You say that this bill is half your monthly income, and you should be reimbursed a partial amount. The Plan denied your request. The Plan says that this provider has chosen to opt out of Medicare which means you will not receive reimbursement.
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 does not say in clear and accurate terms that supplemental services are not covered from opt-out providers. We looked at your contract with the Plan. We did not see where the contract says enrollees cannot receive supplemental dental services from an opt-out-provider. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to pay for the dental services provided on August 2, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided January 11, 2021, and January 21, 2021.
You asked the Plan to pay for the periodontal scaling and root planing. You say that you feel your 2021 contract benefits should not take past services into consideration for frequency limits. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the periodontal scaling and root planing once per quadrant every three years. We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal scaling and root planing was previously covered on February 11, 2020, and February 14, 2020. Based on this rmation, we decided that the Plan's frequency limit for coverage of the periodontal scaling and root planing has been exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341) provided January 11, 2021, and January 21, 2021.
Your complaint about the Plan using previously covered services when considering coverage limits under your 2021 policy 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Prolia injection you had on May 25, 2021.  You asked the Plan to waive the coinsurance for the Prolia injection. You say that you believe this coinsurance is too expensive. The Plan denied your request. The Plan says you were charged this coinsurance 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 Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B drugs 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 the Prolia injection you had on May 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to adjust the copayment for the duplex scan of the extracranial arteries; complete bilateral study (93880) provided on June 29, 2021.  You asked the Plan to adjust 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 $90 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).   You have been asked to pay a $90 copayment for the Medicare-covered radiological diagnostic service 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 adjust the copayment for the duplex scan of the extracranial arteries; complete bilateral study (93880) provided on June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic mammogram and breast ultrasound you had on June 25, 2021.  You asked the Plan to waive the copayment for the diagnostic mammogram and breast ultrasound. You say that you had your annual mammogram on June 14, 2021.  They could not read the results, so you were advised to return for a second mammogram.  When they couldn't read those results either, you were given an ultrasound. You do not think you should have to pay for this second mammogram or ultrasound since you did not request this service.  You said that no one told you that there would be a charge, and no one asked for your insurance information. The Plan denied your request. The Plan says you were charged this cost sharing correctly.  The Plan says that you are only covered for one screening mammogram per year at no cost, and that was done on June 14, 2021.  The Plan says that you signed and initialed the "screening Diagnostic and Billing Notice" when you received these services that advised you that the second mammogram you were receiving was not considered routine and diagnostic cost sharing would apply.  This document also stated that the breast ultrasound would be subject to your Plan's cost sharing.  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 diagnostic mammograms and a $75 copayment for ultrasounds.   Although the copayments for the diagnostic mammogram ($150) and the ultrasound ($75) total $225, the total allowed amount for these two services ($188.74) is less than your copayment obligation.  That is why you are being charged the full allowed amount.  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 diagnostic mammogram and breast ultrasound you had on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673) provided on May 25, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673) provided on May 25, 2021.