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

 We decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis (PT) code 81599) provided to the enrollee on December 31, 2020, by out-of-network providers.  

You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for unlisted multianalyte assay with algorithmic analysis (PT) code 81599) provided to the enrollee on December 31, 2020, by out-of-network providers.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 and the
electrocardiogram coded 93010 provided on July 11, 2021.

You asked the Plan to pay for the emergency department visit and the electrocardiogram. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed
were already processed.

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 CPT codes 99285 and 93010 are not supported in the medical record. Specifically, the
documentation supports one unit of each of these services, which were previously approved and paid by the
Plan. There is no additional documentation supporting additional services which were billed. Based on this
information, we decided that Medicare rules for coverage of the emergency department visit and the
electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the
emergency department visit coded 99285 and the electrocardiogram coded 93010 provided on July 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the botox provided on August 24, 2021.

You asked the Plan to waive the coinsurance for the botox. You say that you don't believe insurance should be
charged for the discarded portion. You say that you shouldn't be charged a copayment for medical services
never administered. The Plan denied your request. The Plan says the coinsurance 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 Medicare-covered Part B chemotherapy, prescription drugs and immunizations from a network
provider.

You have been asked to pay $168.56, which is 20% of the allowed amount for the wasted portion of the botox.
The allowed amount is $842.80 (20% x $842.80 = $168.56). The botox falls within the "Medicare Part B
prescription 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 botox provided
on August 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on September 15, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 70544 may be eligible for payment when billed with CPT code 70551. The claim information does not show that code 70544 was billed with a modifier that was appropriately appended. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D hydroxy coded 82306 provided on August 5, 2021.

You asked the Plan to pay for the Vitamin D hydroxy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The documentation did not include medical records for the services rendered. This means the Vitamin D hydroxy test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D hydroxy coded 82306 provided on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of abdomen, 1 view (CPT code 74018) provided to the enrollee on January 31, 2021.

You asked the Plan to pay for the x-ray. You say that the provider billed three (3) units, two (2) paid and this claim denied as a duplicate. You state the provider submitted radiology report for 2 units from which you can tell, which would support the 2 units that paid. You state PER Kl 3 units per day are allowed. The Plan denied your request. The Plan says the service is not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The enrollee had professional interpretation of an abdominal x-ray by this provider on January 31, 2021. The submitted documentation supports 1 (one) unit of 74018-26, which was previously approved/paid. There is no additional documentation supporting an additional study which was billed and remains denied.

Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray of abdomen, 1 view (CPT code 74018) provided to the enrollee on January 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance service, basic life support, non-emergency transport provided on July 26, 2021.  

You asked the Plan to waive the copayment for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the claim processed 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 $200 copayment for Ambulance Services.   

You have been asked to pay a $200 copayment for ambulance service, basic life support, non-emergency transport. The ambulance service, basic life support, non-emergency transport falls 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 service, basic life support, non-emergency transport provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered on June 28, 2021.

You asked the Plan to waive the copayment for these services. You say that you were advised by the provider 
that you had a $10 credit. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care 
provider. 

Review of the file shows that you had a primary care provider (PCP) office visit on June 28, 2021. You have 
been asked to pay a $10 copayment for these services. These services fall within the covered visit or 
consultation in an outpatient location with your PCP or other primary care provider 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. The Plan cannot be held 
responsible for possible misinformation regarding your copayment responsibility given by a provider. 
Therefore, we decided that the Plan does not have to waive the copayment for the office visit rendered on June 
28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of chest, 1 view (CPT code 71045) provided to the enrollee on July 2, 2020.
You asked the Plan to pay for the x-ray. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The enrollee had professional interpretation of a chest x-ray by this provider on July 2, 2021. The submitted documentation supports 1 (one) unit of 71045-26, which was previously approved/paid. There is no additional documentation supporting an additional study by this provider which was billed and remains denied.
Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray of chest, 1 view (CPT code 71045) provided to the enrollee on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01924) provided June 1, 2021.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the anesthesia services were not billed with an appropriate surgical 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 find that CPT code 01924 is not supported in the medical record. Specifically, no surgical procedure code that crosswalks with the billed anesthesia code was reported. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01924) provided June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing provided on July 19, 2021.
You asked the Plan to pay for GeneSight testing. You say that no basis exists for the Plan to deny payment for this testing. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered, was not billed correct, and was not medically necessary.
The Plan follows Medicare rules. Medicare rules state that pharmacogenomics testing may be covered under certain circumstances. 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 GeneSight testing. Our reviewer says that this testing does not meet criteria for payment. Our physician reviewer found the case file contains a GeneSight Order Medical Necessity Documentation form, and the results of the GeneSight testing. The case file does not contain additional clinical information for review. The documentation is insufficient to support that the GeneSight genetic testing was medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing provided on July 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound services (76775, 76857) 
provided on August 4, 2021.

You asked the Plan to waive the copayment for the ultrasounds. You say that you have had these ultrasounds in 
previous years, and they were covered in full by the Plan. The Plan denied your request. The Plan says this 
claim was processed correctly, and your copayment was assessed in accordance with your contract. You must 
pay a $155 copayment for radiological diagnostic services such as ultrasounds. The Plan's allowed amount 
(discounted rate) for these services is less than your required copayment, so you are being asked to pay the 
lesser amount in this case.

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 $155 
copayment for Medicare-covered radiological diagnostic services. 

You have been asked to pay a $99.36 copayment for the ultrasounds. Ultrasounds fall within the Medicarecovered radiological diagnostic 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 ultrasound services (76775, 76857) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Urine PCR panel testing (CPT code(s): 87798, 87653, 87640, 87500, 87481) provided to the enrollee on January 14, 2021.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the PCR testing is considered unproven and not medically necessary.  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 laboratory services. Our physician reviewer found the review indicates that the enrollee has a past medical history is significant for acute kidney injury, Alzheimer's disease, hypertension, and coronary artery disease. Based on submitted documentation, this enrollee is experiencing recurrent urinary tract infections. Currently denies signs/ symptoms of infection since last visit. Does experience slow urinary stream and has frequency every hour and nocturia x2. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. The PCR testing is considered unproven and not medically necessary. The review has determined that the medical records provided do not meet the requirements listed in the NCD for Medicare coverage. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the Urine PCR panel testing (CPT code(s): 87798, 87653, 87640, 87500, 87481) provided to the enrollee on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional resin-based composites and pulp cap provided on July 29, 2020.

You asked the Plan to pay for the additional resin-based composites and pulp cap. You say that you had 12 fillings but only one was covered. You say that you need help paying the $880 still owed. The Plan denied your request. The Plan says the claim processed 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 maximum benefit of one filling per calendar year. The Plan paid for one resin-based composite provided on July 29, 2020, which exhausted your benefit. The pulp cap remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the additional resin-based composites and pulp cap provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on August 12, 2021, to August 15, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this copayment amount
is way too high. The Plan denied your request. The Plan says the correct copayment has been 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 $275
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay a $275 copayment per day for days 1-3 for an inpatient hospital stay. The EOC
says that the day before you are discharged is your last inpatient day. You are being asked to pay a total of
$825 ($275 x 3 days = $825). An inpatient hospital stay falls within the inpatient hospital care benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating
provider on August 12, 2021, to August 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport service provided on June 11, 2021.

You asked the Plan to pay for the ambulance transport service. You say that you say that one ambulance took you to the hospital, but you are being billed by another ambulance provider. You also say that you could not be taken to the hospital in two ambulances. The Plan denied your request. The Plan says you were provided a non-transporting/paramedic intercept service on this date of service. The Plan also says that paramedic intercept is a non-covered ambulance service.

The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. 

The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the ambulance transport service provided on June 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for consultation and report on referred slides prepared elsewhere 
(CPT code 88321) provided to the enrollee on May 5, 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 CPT 88321-1 Unit was not billed in accordance with Medicare National Correct Coding 
Initiative Policy - Medically Unlikely Edits (MUE). The Plan states CPT 88321-1 Unit has an MUE value of 
"1", and the provider billed "2" units.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Per review of CMS MUE 
Practitioner Services 2021 File shows 88321-1 Unit has the MUE value of "1" with MUE Adjudication 
Indicator as "2 Date of Service Edit" and per NCCI Chapter 1 Section "V" it states: MUES for HCPCS codes 
with an MAI of "2" are absolute date of service edits. These are "per day edits based on policy". HCPCS codes 
with an MAI of "2" have been rigorously reviewed and vetted within CMS and obtain this MAI designation 
because UOS on the same date of service (DOS) in excess of the MUE value would be considered impossible 
because it was contrary to statue, regulation, or subregulatory guidance. This subregulatory guidance includes 
clear correct coding policy that is binding on both providers and CMS claims processing contractors. 
Limitations created by anatomical, or coding limitations are incorporated in correct coding policy, both in the 
HIPAA mandated coding descriptors and CMS approved coding guidance as well as specific guidance in CMS 
and NCCI manuals. As a result, claims processing contractors are instructed that an MAI of "2" denotes a 
claims processing restriction for which override during processing, reopening, or redetermination would be 
contrary to CMS policy. Therefore, we decided that the Plan does not have to pay for consultation and report 
on referred slides prepared elsewhere (CPT code 88321) provided to the enrollee on May 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan of extracranial arteries; 
complete bilateral study (93880) provided August 16, 2021.

You asked the Plan to waive the copayment for the ultrasound of both sides of head and neck blood flow. You 
say that you feel you should be charged a $15 copayment for diagnostic tests and procedures. The Plan denied 
your request. The Plan says the copayment was applied correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a
physician's office or at a free-standing facility.

You have been asked to pay a $125 copayment for the ultrasound of both sides of head and neck blood flow. 
The ultrasound of both sides of head and neck blood flow falls within the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. This service is considered a radiological diagnostic service. 
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 duplex scan of extracranial arteries; complete bilateral 
study (93880) provided August 16, 2021.