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

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 19, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you do not know where the $200 charge is coming from. 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 $200 copayment for each one-way ground ambulance trip. 

You have been asked to pay a $200 copayment for the ambulance services. Ambulance services fall within the Ambulance 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 ambulance services provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided on July 27, 2021.
You asked the Plan to pay for the office visit. You say that you should not be charged as no services were rendered. The Plan denied your request. The Plan says an outbound call was made to the provider to verify this information, and they requested medical records, which the Plan did not receive. The Plan states without the necessary information to determine if the services were rendered or not, the Plan cannot review the claim thoroughly. The Plan states you will not be held responsible for the services until the Plan's Special Investigation Unit completes their review on the case or until we receive documentation for the services. The Plan states the claim has been reprocessed to remove your responsibility, until the review is completed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Without the necessary information to determine if the services were rendered or not, we cannot review the
claim thoroughly. However, you will not be held responsible for the services until the Plan's Special Investigation Unit completes their review on the case or until the Plan receives documentation for the services. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99214) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673), provided on May 12, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The Plan denied your request. The Plan says this device is not covered when used as a preventative device during or after surgery.  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 E0673), provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services coded 99291 provided on June 9, 2021.  You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.    We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not include a critical care visit of 30-74 minutes that was performed for the billed date of service. The documentation does not include the time spent providing this service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D laboratory testing provided to the enrollee on July 22, 2021.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says preventative/screening vitamin assays and metabolic function tests are not a covered benefit.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found Medicare considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, non-covered. Similarly, assays for micronutrient testing for nutritional deficiencies that include multiple tests for vitamins, minerals, antioxidants and various metabolic functions are never necessary. The review has determined that the services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D laboratory testing provided to the enrollee on July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided July 8, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code 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 radiology services (70450) provided July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia complicated by emergency conditions (specify) (CPT code 99140) provided to the enrollee on May 21, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99140, which has a status indicator of 'B' on the CMS Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment Is made per Medicare. 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 anesthesia complicated by emergency conditions (specify) (CPT code 99140) provided to the enrollee on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (procedure 95999) provided to the
enrollee on October 13, 2020.
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 this service is considered a bundled procedure as the cost is included in the cost of the primary
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.
In this case, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular
diagnostic 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 the services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found there is no separate code assigned for
Train of Four testing. The procedure is bundled with the intraoperative neuromonitoring of electromyography
(EMG) or motor evoked potentials (MEP), and therefore, is not separately reportable.
We looked at this coder's review, the file, and Medicare rules. 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 neurology services (procedure 95999) provided to the enrollee on October 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided on September 29, 2020.

You asked the Plan to pay for wound debridement. You say that you have appropriately applied the level of service in compliance with the guidelines which is supported in the provider's documentation. You say that the claim should be reprocessed appropriately. The Plan denied your request. The Plan says The Plan says that CPT code 99285 was approved. The Plan says that CPT 97597 remains denied as an appropriate modifier was not billed with this code edit.

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 97597 is a column II code to column I code 12002. 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 wound debridement provided on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate for the
enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no evidence of moderate to severe symptoms.
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 pre-approve the procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Medicare coverage criteria have not been met. Specifically, the International Prostate
Symptom Score (IPSS) is not greater than 12 and maximum flow rate was not provided.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve transurethral waterjet ablation of prostate for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coronavirus (COVID-19) test obtained outside the United States for travel purposes purchased on September 14, 2021.

You asked the Plan to pre-approve the test. You say that you are requesting reimbursement of services rendered. You state that you were outside the United States and you were required to obtain a Coronavirus test to be able to return to the United States. The Plan denied your request. The Plan says Medicare does not cover items or services that are not medically necessary and does not cover services provided outside the United States.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test have not been met. The Coronavirus test that you obtained on September 14, 2021, was not an urgent or emergent service and was not ordered/prescribed by a provider for diagnosis or treatment of an illness. The test was performed for travel purposes only. Therefore, we decided that the Plan does not have to pre-approve Coronavirus (COVID-19) test obtained outside the United States for travel purposes purchased on September 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires (A4557) provided to the enrollee on April 13, 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 this was not coded correctly.

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 Healthcare Common Procedure Coding System (HCPCS) code A4557 is "Lead wires, (e.g., apnea monitor), per pair."

We find that HCPCS code A4557 is not supported in the medical record. Specifically, this code has a status indicator of "P" which means that payment for this code is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lead wires (A4557) provided to the enrollee on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility service provided on November 24, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the skilled nursing facility service. You say that the service was provided with no adequate time frame to obtain authorization for the service. You say the service was medically necessary. 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 skilled nursing facility service provided on November 24, 2020, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services coded as 99601 provided from May 21, 2021, through May 25, 2021.
You asked the Plan to pay for the home infusion services. You say that you would like this claim reprocessed based on the medical documentation submitted. The Plan denied your request. The Plan says this claim has been billed with a code that is deemed not valid for Medicare purposes.
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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status code "I" under the Physician Fee Schedule which indicates that it is not valid for Medicare purposes. Specifically, Medicare uses another code for reporting of, and payment for, these services. Based on this information, we
decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services coded as 99601 provided from May 21, 2021, through May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880).
You asked the Plan to pre-approve an occlusal device. You say that this item is necessary to relieve your temporomandibular joint (TMJ) disorder and resulting headaches. The Plan denied your request. The Plan says this item is not covered by Medicare or by your dental benefit.
Oral appliances generally are classified as dental devices and are not classified as Durable Medical Equipment (DME). Oral occlusal appliances used to treat TMJ disorders are considered to be dental devices under Medicare, and will be denied as non-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. The Plan's contract states that dental splints, dental prosthesis, or any dental treatment for the teeth, gums, or jaw or dental treatment related to temporomandibular joint syndrome (TMJ) are not covered under any condition. 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 or under Original Medicare. Therefore, we decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 22, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you were never told the provider was out-of-network and never told you needed a referral. 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 January 22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (procedure codes 80307 and G0483) provided to the enrollee on May 11, 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 procedure code 80307 has not met the associated frequency relationship criteria.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there was no specific clinical rationale for the obtained testing. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (procedure codes 80307 and G0483) provided to the enrollee on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for provisional crown (D2799), limited oral evaluation (D0140), periapical radiographic image (D0220), provided on August 2, 2021.
You asked the Plan to pay for the dental services. You say that the service was medically necessary. The Plan denied your request. The Plan says you did not receive this service is in-network.
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 provisional crown (D2799), limited oral evaluation (D0140), periapical radiographic image (D0220), provided on August 2, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (80307) provided on April 22, 2021.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says that this does not meet the associated frequency relationship criteria.
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 rules also say that it is not appropriate to report more than twelve (12) presumptive urine drug testing (UDT) (code 80305, 80306, or 80307) services per calendar year. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan states that the testing at issue was denied due to frequency, the Plan has not provided any documentation showing when the enrollee previously received this testing. Therefore, we decided that the Plan has to pay for drug testing (80307) provided on April 22, 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