Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 3, 2021.
You asked the Plan to reimburse you an additional amount for the eyeglasses. The Plan denied your request. The Plan says the benefit of $250 allowance was applied to the purchase, leaving you with a responsibility of $69.97, which was paid at the time of purchase. The payment of $250 was sent via check to the member on October 12, 2021.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the benefit of $250 allowance was applied to the
purchase, leaving you with a responsibility of $69.97, which was paid at the time of purchase. The payment of
$250 was sent via check to you on October 12, 2021. Therefore, we decided that the Plan does not have to
reimburse you an additional amount for eyeglasses provided on September 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on March 1, 2021.
You asked the Plan to pay for the ambulance service. You say that there was no transport needed as your condition approved as the paramedics attended to your care. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since there was no transport provided there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 1, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for advanced imaging services received on September 16, 2021.
You asked the Plan to waive the copayment for the services. You say that a representative told you there shouldn't be any copayment. 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 $175 copayment for advanced radiology diagnostic services. You have been asked to pay $126.84 for the services. The scan falls within the advanced radiology diagnostic services benefit category, and has an allowed amount ($126.84) less than the usual copayment for the services. 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 advanced imaging services received on September 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the exploration of spinal fusion (22830), laminotomy (63042) and fluoroscopy (76000) provided on July 13, 2021.
You asked the Plan to pay for the exploration of spinal fusion (22830), laminotomy (63042) and fluoroscopy (76000). You say that the patient underwent an emergency lumbar spine surgery which is considered standard of care and medically necessary. You say that these are not inclusive to any other procedure and the claim should be reconsidered for appropriate reimbursement. The Plan denied your request. The Plan says CPT code 22830 and 63042 are included in the global period from the procedure performed on June 23, 2021. The Plan also says that an appropriate modifier was not billed with 76000 to bypass the edit.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. Medicare rules say that the Correct Coding Initiative was developed to promote correct coding and to control improper coding leading to inappropriate payment in Part B claims. CPT code 22612 has a global period of 90 days. CPT code 22830 and 63042 were billed within 90 days by the same provider. The modifier billed does not indicate the services are unrelated to the procedure performed on June 23, 2021. In this case, we have confirmed that code 76000 is a column II code to column I code 63042. CPT code 76000 has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the exploration of spinal fusion (22830), laminotomy (63042) and fluoroscopy (76000) have not been met. Therefore, we decided that the Plan does not have to pay for the exploration of spinal fusion (22830), laminotomy (63042) and fluoroscopy (76000) provided on July 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) colonography provided to the enrollee on August 3, 2021.
You asked the Plan to pay for the scan. You say that this claim should be reprocessed for payment. The Plan denied your request. The Plan says experimental or investigational services are not covered
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Screening computed tomographic colonography is not a covered service. The diagnosis for this scan was on the order form was "screening for malignant neoplasm of colon." Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) colonography provided to the enrollee on August 3, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on September 17, 2021.
You asked the Plan to pay for the X-ray exam of the chest. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the claim 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 looked at the file and Medicare rules. In this case, the Plan has paid for one unit of 71045. The documentation submitted does not support payment for additional X-ray services beyond what was paid. Based on this information, we decided that Medicare rules for coverage of the X-ray exam of the chest have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray exam of the chest (71045) provided on September 17, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) and coronectomy (D7251) provided on July 19, 2021.

You asked the Plan to pay for the dental services. You say that these services were medically necessary. The Plan denied your request. The Plan says the coronectomy is not a covered service under your dental benefit. The limited evaluation is a covered service but is limited to one instance per year. You had a previous limited oral evaluation on July 15, 2021, which was covered and paid for by the Plan at that time. Therefore, the limited exam provided on the date in question exceeds the frequency limitation of your 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. The Plan does not cover supplemental dental services that are not listed in the contract. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year.

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 were provided in a frequency that exceeds what is covered by the benefit. Documentation shows that you had a previous limited oral exam in the same plan year which was covered at that time. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) and coronectomy (D7251) provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection (87481, 87640, 87651, 87653, 87798, 88305) and special stain (88312) provided on August 17, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not meet Medicare criteria for coverage.

The Plan follows Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. 

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 reviewer says that based on national coding and payment standards, there is insufficient diagnosis and service information in
the available patient data to explain and support multiple infectious detection tests for common nail/feet concerns. Our physician reviewer found there is insufficient diagnosis and service information in the available patient data to explain and support a special stain (code 88312) for nail pathologies. The review has determined that the documentation submitted does not support the medical necessity of the billed CPT codes. 

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 infectious agent detection (87481, 87640, 87651, 87653, 87798, 88305) and special stain (88312) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services, medical
examination and evaluation provided on September 13, 2021.
You asked the Plan to waive the copayment for the ophthalmological services, medical examination, and
evaluation. The Plan denied your request. The Plan says the claim processed appropriately according to the
billing of the provider for services rendered and the structure of your benefit Plan. You are covered for routine
eye exam but the services you received were not considered preventative and/or routine.
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 Vision Care.
You have been asked to pay a $10 copayment for the ophthalmological services, medical examination, and
evaluation. The ophthalmological services, medical examination, and evaluation falls within the Vision 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 ophthalmological services,
medical examination and evaluation provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 11, 2021, by an OON
provider.

You asked the Plan to pay for the office visit. You say that 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 office visit provided on March 11, 2021, by an OON
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 16, 2020.

You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says the claim was received on October 20, 2021, which is past the allowed 12-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the hearing aids was not filed until October 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections.

You asked the Plan to pay for the injections. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications established in the applicable LCD. 

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 injections. Our reviewer says that the requested injections are not medically reasonable and necessary. Our physician reviewer found that the enrollee's disc bulge is another probable source of her back pain.

Therefore, she does not meet the criteria of the LCD and the procedure is not considered 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 injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services represented by code 00630 for date of
service June 25, 2021.
You asked the Plan to pay for code 00630. You say that the medical records provided support that payment
should be made on the code in dispute. The Plan denied your request. The Plan says the anesthesia services
reported are inconsistent with the surgical procedure reported.
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 00630 is Anesthesia for procedures in lumbar region; not
otherwise specified.
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 code 00630. Our reviewer says that the criteria for coverage
have not been met. Our reviewer found the documentation does not include an operative report to confirm the
correct anesthesia code to report. The Plan states that the procedure performed was a Percutaneous
implantation of neurostimulator electrode array, epidural. Anesthesia report documents "SCS Trial" with
diagnosis of "Radiculopathy". Code 00630 represents Anesthesia for procedures in lumbar region; not
otherwise specified. A procedure code should be reported to the highest specificity. In this case, the procedure
performed is not coded to the highest specificity. An SCS Trial is performed through percutaneous lead
placement, and is image guided. A more specific code should be reported for this procedure. Code 01936
represents anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 00630 have not been met. Therefore, we decided that the Plan does not
have to pay for anesthesia services represented by code 00630 for date of service June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 18, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 laboratory services at issue in this appeal were 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 laboratory services provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 11, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that 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 office visit provided on May 11, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from September 4, 2021, through September 7, 2021.

You asked the Plan to pay for the physician's services. You say that the date of service is after the termination of the patient's hospice period; therefore, the Plan is responsible for the payment of the claim. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. 

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on September 3, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided from September 4, 2021, through September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the routine ophthalmological examination
including refraction (S0620) rendered by the OON provider on April 7, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to issue reimbursement for this service. Therefore, we
decided that the Plan does not have to issue reimbursement for the routine ophthalmological examination
including refraction (S0620) rendered by the OON provider on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound of the abdomen (76700) provided on August 18, 2021.

You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 76700 and 93976.

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 76700 is a column II code to column I code 93976. 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 ultrasound of the abdomen (76700) provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 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 testing is not covered.

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 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 laboratory services rendered on August 2, 2021.