Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational
therapist on March 16, 2021.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay noncontracted
providers at the preferred provider rate if services are not available from preferred providers in the
service area. You say that the in-network benefits should be honored, and the claim processed for payment. The
Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as
services incident to a physician/non-physician practitioner's service must meet all incident requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse
practitioner. As such, occupational therapist services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided
by an occupational therapist on March 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional 5 physical therapy sessions provided by a participating provider.
You asked the Plan to pay for physical therapy. You say that the additional therapy sessions are medically necessary. The Plan denied your request. The Plan says additional therapy services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are not medically 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on October 20, 2020.
You asked the Plan to pay for code 99291. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on July
23, 2021.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was a routine
mammogram, and you should not owe a copayment. 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 $40
copayment for x-rays and ultrasounds.

The medical records show that you received a diagnostic mammogram on July 23, 2021, due to a personal
history of breast calcifications. Therefore, you are responsible to pay the $40 copayment.

You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
April 9, 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 physician services provided to the
enrollee on April 9, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (G0483) provided on December 8, 2020.
You asked the Plan to pay for the laboratory service. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory service (G0483) provided on December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detox treatment.
You asked the Plan to pre-approve inpatient detox treatment. You say that the requested admission to an inpatient detox is medically necessary. The Plan denied your request. The Plan says the requested admission to an inpatient detox does not meet 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 pre-approve inpatient detox treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found your records did not clearly show signs and symptoms of acute withdrawal from benzodiazepines to help justify this request for inpatient detox.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient detox treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient detox treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).
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).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (O242U) provided July 5, 2021.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 is covered for patients who have decided to seek further cancer treatment. We looked at the file and Medicare rules. The record shows the enrollee elected hospice care and did not seek further treatment. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (O242U) provided July 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery procedures coded as 69706 provided on April 21, 2021.
You asked the Plan to pay for the surgery procedures. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says no modifiers are allowed with this PTP code pair according to Medicare rules.
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 69706 is a column II code to column I code 31295. This claim has a PTP edit of 0 indicating that no modifiers are allowed with this PTP code pair. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the surgery procedures coded as 69706 provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 30, 2021.

You asked the Plan to pay for this service. 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 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 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 physician services provided to the enrollee on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram coded 93010 provided on March 24, 2021.
You asked the Plan to pay for 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 are not 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 93010 for the electrocardiogram is a column II code to column I code 31500. 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 the electrocardiogram coded 93010 provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded as 01992 provided May 19, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has denied 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. 

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 01992 is a column II code to column I code 64483. Specifically, this PTP edit has a modifier indicator of 0 which indicates no modifiers are allowed for this claim. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 01992 provided May 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services
coded 99601 provided on April 9, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration 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 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, 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 of
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided
that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601
provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services received on June 10, 2021.
You asked the Plan to pay for the surgery services. You say that you feel this service should be coded as a
medical procedure and not a dental procedure. The Plan denied your request. The Plan says the services
received are not a covered benefit when provided by a provider that does not accept payment from Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
surgery services received on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty (D4212) provided on
February 24, 2021.
You asked the Plan to pay for the gingivectomy or gingivoplasty (D4212). You say that this procedure was
necessary to cut away teeth and give access to restorations. You say that you tried everything dental and asked
if they would roll it over to medical insurance to get the claim paid. The Plan denied your request. The Plan
says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
gingivectomy or gingivoplasty (D4212) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99205 provided on March 23, 2021.
You asked the Plan to pay for the office visit. 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 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 99205 for the office visit is a column II code to column I code 77263. 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 the office visit coded 99205 provided on March 23, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).

You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following 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 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).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81432, 81437, 81236, 81218, 81407) provided March 15, 2021.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT codes 81432, 81437, 81236, 81218 and 81407 are not supported in the medical record. Specifically, per Medicare National Coverage Determination - Next Generation Sequencing (NGS) (90.2), for a Comprehensive Genetic Testing panel, providers should report one unit of CPT 81479. In this case, multiple unbundled codes were billed. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met.
Therefore, we decided that the Plan does not have to pay for genetic testing (81432, 81437, 81236, 81218, 81407) provided March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for intraperitoneal procedures (00840) provided on November 12, 2020.
You asked the Plan to pay for the anesthesia for intraperitoneal procedures. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says they have insufficient documentation to corroborate the services provided.
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 00840 is anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified.
We find that CPT code 00840 is not supported in the medical record. Specifically, no medical records were provided for the date of service. Without these medical records, we cannot corroborate the services as billed. Based on this information, we decided that Medicare rules for coverage of the anesthesia for intraperitoneal procedures have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for intraperitoneal procedures (00840) provided on November 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for x-ray exams of the neck, spine (72040), and an x-ray exam of the spine; thoracolumbar junction (72080) rendered from June 7, 2021, to June 14, 2021.

You asked the Plan to waive the deductible for x-ray exams of the neck, spine and an x-ray exam of the spine; thoracolumbar junction. You say that your explanations of benefits indicate this is for above reasonable and customary charges. You also say you believe the provider is out of network. The Plan denied your request. The Plan says you were 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 $500 out-of-network deductible for non-Medicare-covered x-ray services performed by a chiropractor (you would pay this in addition to your visit). 

You have been asked to pay a $103.47 deductible for x-ray exams of the neck, spine and an x-ray exam of the spine; thoracolumbar junction ($67.77 allowed amount for date of service June 7, 2021 + $35.70 allowed amount for date of service June 14, 2021 = 103.47). X-ray exams of the neck, spine and x-ray exams of the spine; thoracolumbar junction fall within the Chiropractic 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 deductible for x-ray exams of the neck, spine (72040), and an x-ray exam of the spine; thoracolumbar junction (72080) rendered from June 7, 2021, to June 14, 2021.