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

We decided that the Plan does not have to pay for the diagnostic radiology services provided on August 8, 2021.
You asked the Plan to pay for the services provided. You say that the records support the procedure was performed. The Plan denied your request. The Plan says the code was previously paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
The file shows that a chest x-ray and computed tomography (CT) scan were provided. The records in the case file show that the services at issue were approved and paid for by the Plan on a previous claim. The medical records do not indicate that additional tests were provided on this date of service. We find no exception which would require the Plan to provided additional payment for the services. Therefore, we decided that the Plan does not have to further pay for the diagnostic radiology services provided on August 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan of the head or brain (70450) provided on February 11, 2021.
You asked the Plan to pay for a CT scan of the head or brain. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the request is a duplicate of a prior claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the head or brain have not been met. Specifically, the Plan has documented that the claim at issue is a duplicate of a prior claim that has been processed and paid. Therefore, we decided that the Plan does not have to pay for a CT scan of the head or brain (70450) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided to the enrollee on June 3, 2021.
You asked the Plan to pay for these services. You say that neither the enrollee nor the provider knew they were not in network. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided to the enrollee on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (00300) provided on September 25, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim must be first sent to the enrollee's primary insurance carrier.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has indicated the primary insurer that must be billed in the decision letter that has been issued. As the secondary insurer, the Plan cannot be held responsible for the anesthesia services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00300) provided on September 25, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenomics testing panel provided on March 5, 2021.
You asked the Plan to pay for the testing services. You say that the treatment was medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says only one code must be submitted.
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 looked at the file and the rules. We find that the gene panel was billed with multiple procedure codes. If a
single procedure is performed, only one with one unit of service may be reported for the procedure. Based on
this information, we decided that Medicare rules for coverage of the testing services have not been met.
Therefore, we decided that the Plan does not have to pay for the pharmacogenomics testing panel provided on
March 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on August 18, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.]
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided to the enrollee on August 18, 2021.
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 the reporting of multiple infectious agent detection tests for common urinary tract infection
concerns must be supported by diagnosis and service information in the available patient data.
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 that in this case, the provider did not bill as required by Medicare coding regulations. The review also
indicates that the services at issue in this case were 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for mouthwash purchased on August 9, 2021.
You asked the Plan to reimburse you for mouthwash. The Plan denied your request. The Plan says mouthwash is ineligible for reimbursement.
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list. We looked at the file and the Plan's rules. The file shows that over-the-counter items must be included on the Plan's allowed items list. Mouthwash is ineligible for reimbursement. Therefore, we decided that the Plan does not have to reimburse you for mouthwash purchased on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided from July 28, 2021, through August 5, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation.
We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided from July 28, 2021, through August 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from May 29, 2021 to June 30, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that Medicare requires all home health agency billing claims to be submitted on the Form CMS-1450/UB-04 hard copy form. We looked at the file and Medicare rules. The file shows that the claims were not billed on the required CMS-1450/UB-04 hard copy form. 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 home health services rendered from May 29, 2021 to June 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace (L2397), provided on June 8, 2021.
You asked the Plan to pay for the knee brace. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no documentation of injury or surgery.
The Plan must follow Medicare rules. Medicare rules state that a knee immobilizer without joints, or a knee orthosis with adjustable knee joints, or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control, are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee brace have not been met. Therefore, we decided that the Plan does not have to pay for the knee brace (L2397), provided on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of a joint of the lower extremity (73721) provided on June 12, 2021.
You asked the Plan to waive the copayment for an MRI scan of a joint of the lower extremity. You say that the services at issue were mistakenly codded as out-of-network. The Plan denied your request. The Plan says the correct copayment 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 $200 copayment for diagnostic radiology other than computed tomography (CT) scans when these services are provided in-network.
You have been asked to pay a $200 copayment for an MRI scan of a joint of the lower extremity. An MRI scan
of a joint of the lower extremity 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 MRI scan of a joint of
the lower extremity (73721) provided on June 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided from January 11, 2021, through January 20, 2021.
You asked the Plan to pay for the additional supplies and materials. You say that 99072 was established to report additional practice expenses during a Public Health Emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from January 11, 2021, through January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliances (E0669 x2).
You asked the Plan to pre-approve a pneumatic compression device and pneumatic appliances. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when specific criteria are met. 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 a pneumatic compression device and pneumatic appliances. Our reviewer says that the items are not medically necessary. Our physician reviewer found the record provided does not document that you have had failure of a basic compression device. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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 pneumatic compression device and pneumatic appliances have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliances (E0669 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion therapy provided on August 13, 2021 by an out-of-network (OON) provider.
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 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 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 the infusion therapy provided on August 13, 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 ultrasound services provided on May 7, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
We looked at the file and the rules. The claim does not show that the services were provided with a modifier suitable for payment. 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 ultrasound services provided on May 7, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail trimming services provided on July 29, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the nail trimming services. You say that you are at a care facility and you were advised at the home you were at that the service would be covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the nail trimming services provided on July 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on May 24, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network services provided to the enrollee on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit (99205), the tympanometry and reflex threshold measurements (92550), and the comprehensive audiometry threshold evaluation and speech recognition (92557) provided on July 5, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services 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 $35 copayment for Medicare-covered hearing services. A specialist copayment also applies if services are provided during a specialist visit. You must pay a $30 copayment for each Medicare-covered specialist visit. You have been asked to pay $65 for the services provided. This includes a $35 copayment for the Medicare-covered hearing services provided. Additionally, this amount includes a specialist copayment of $30 as the contract with the Plan indicates that a specialist copayment may apply if these services are provided during a specialist visit. 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 copayments for the office visit (99205), the tympanometry and reflex threshold measurements (92550), and the comprehensive audiometry threshold evaluation and speech recognition (92557) provided on July 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on July 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 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 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 computed tomography (CT) scan of the head/brain rendered on July 27, 2021.