Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 We decided that the Plan has to reduce the cost share for the coinsurance applied for the medical/surgical supplies. We decided that the Plan does not have to reduce the cost share for the Part B drugs, the outpatient surgery, and the specialist services.   You asked the Plan to reduce the cost share for the Part B drugs, the outpatient surgery, and the specialist services. You say that you would like the Plan to reconsider your request. The Plan says that the correct cost share has applied.  We decided that the Plan has to reduce the cost share for the coinsurance applied for the medical/surgical supplies.   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 does not document that the 20% coinsurance for Part B drugs also applies to medical/surgical supplies used for a procedure. Therefore, we decided that the Plan has to reduce the cost share for the coinsurance applied for the medical/surgical supplies, in the amount of $1879.33. This means that your new coinsurance total for the Part B drugs is $50.39.  We also decided that the Plan does not have to reduce the cost share for the Part B drugs, the outpatient surgery, and the specialist services.  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 20% coinsurance for Part B drugs, a $150 copayment for outpatient surgery, and a $30 copayment for the services provided by a specialist. Your total cost share amount for the services provided on March 18, 2021 is $230.39 ($50.39 Part B drugs + $150 Outpatient surgery + $30 Specialist services).  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, abdominal, real time with image documentation; complete (76700) provided July 7, 2021.  You asked the Plan to waive the copayment for the complete abdominal ultrasound. You say that the doctor ordered the ultrasound based on blood work and you would like the Plan to pay for the medical procedure. 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 $150 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 $110.84 for the complete abdominal ultrasound. This ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. Ultrasounds are considered a radiological diagnostic service. This means that you have been asked to pay less than or equal to 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, abdominal, real time with image documentation; complete (76700) provided July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (00210) provided on June 9, 2021  You asked the Plan to pay for code 00210. 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 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 00210 is Anesthesia for intracranial procedures; not otherwise specified.  We find that CPT code 00210 is not supported in the medical record. Specifically, an appropriate surgical procedure code that crosswalks with the billed anesthesia code was not reported. Based on this information, we decided that Medicare rules for coverage of code 00210 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00210) provided on June 9, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on January 25, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with CPT 81479.  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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant removal (20680) provided on June 23, 2021.  You asked the Plan to pay for the implant removal. You say that you would like reconsideration because this procedure was medically necessary for the treatment of the member. The Plan denied your request. The Plan says this service falls in the global surgery period for CPT code 26418.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 20680 is not supported in the record. Specifically, the record indicates that this service falls in the global surgery period for CPT code 26418. A modifier has not been billed on this claim to indicate a return trip or that this servie sis separately payable. Based on this information, we decided that Medicare rules for coverage of the implant removal have not been met. Therefore, we decided that the Plan does not have to pay for the implant removal (20680) provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a contact lens provided on August 29, 2021.  You asked the Plan to pay for the contact lens. You say that this item is not really a contact lens because there is no prescription and eyeglasses must still be worn. You say this item is needed as a result of several eye surgeries to your left eye, depleting your iris, causing considerable light to enter and causing glare making it difficult to see. The Plan denied your request. The Plan says contact lens coverage only applies for one lens after cataract surgery.  The Plan must follow Medicare rules. Medicare covers prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL.   The Plan contact says that the Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.)  We looked at the file and the Plan's rules. The file shows that the Plan only covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) Therefore, we decided that the Plan does not have to pay for a contact lens provided on August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on August 3, 2021.  You asked the Plan to pay for a comprehensive oral evaluation. You say that you asked for a periodic evaluation knowing you were not eligible for a comprehensive evaluation. You also say you should not be penalized for the provider's error. The Plan denied your request. The Plan says you have exhausted your benefit maximum for this service.  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 covers a comprehensive oral evaluation once every three years.        We looked at the file and Medicare rules. The records show you received a comprehensive evaluation on August 8, 2019; therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99204) provided on August 17, 2021.  You asked the Plan to waive the copayment for the office visit. You say that you would like this copayment waived. The Plan denied your request. The Plan says the copayment has processed correctly 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 $40 copayment for specialist physician services.   You have been asked to pay a $40 copayment for the office visit. This service falls within the specialist physician 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 office visit (99204) provided on August 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychosocial rehabilitation services, per 15 minutes (H2017) provided on July 15, 2021 to July 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the psychosocial services. You say that you live alone and have no one to share with. You need to be in groups to share your life experiences. You 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 psychosocial rehabilitation services, per 15 minutes (H2017) provided on July 15, 2021 to July 30, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasonic guidance for needle placement (76942) provided on August 12, 2021.  You asked the Plan to pay for the ultrasonic guidance for needle placement (76942). The Plan denied your request. The Plan says the clinical value and effectiveness of ultrasound guidance in the setting of trigger point injections has not been demonstrated in the peer-reviewed literature.  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 ultrasonic guidance for needle placement (76942). Our reviewer says that the ultrasonic guidance for needle placement (76942) is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation indicates the enrollee with a history of chronic moderate thoracic pain and muscle spasm. Real time ultrasound was used to ensure no damage to the underlying soft tissue, visceral and vascular structure and intravascular administration did not occur. A total of 3 points were injected and the member tolerated the procedure well. The clinical value and effectiveness of ultrasound guidance in the setting of trigger point injections has not been demonstrated in the peer-reviewed literature. The review has determined that that the ultrasonic guidance for needle placement (76942) at issue in this case is 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 ultrasonic guidance for needle placement (76942) have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasonic guidance for needle placement (76942) provided on August 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided August 29, 2021.  You asked the Plan to waive the copayment for the emergency ambulance services. You say that you were advised by the hospital that you would not have a copayment for the transportation because it was necessary. 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 ambulance transport (one-way).  You have been asked to pay a $125 copayment for the emergency ambulance services. This service 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 the ambulance service, basic life support, emergency transport (A0429) provided August 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies provided to the enrollee on June 18, 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 these are invalid procedure codes for this services.  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 the denied codes is:  99072:  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  A4253:  Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips  A4550:  Surgical trays  A4556:  Electrodes, (e.g., apnea monitor), per pair  A4557:  Lead wires, (e.g., apnea monitor), per pair  A4624:  Tracheal suction catheter, any type other than closed system, each  A4649:  Surgical supply; miscellaneous  S1015:  IV tubing extension set  S8301:  Infection control supplies, not otherwise specified  We find that the denied codes are not supported in the medical record.  Specifically, A4624 has a status indicator of "X" according to the Medicare Physician's Fee Schedule, which means that the code is excluded from coverage.   S1015 and S8301 each have status indicators of "I" according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes.  In terms of A4550 and 99072, these codes have a status indicator of "B" according to the Medicare Physician's Fee Schedule. This means that these codes cannot be paid for separately, and is always bundled into payment for other services not specified.  A4557, A4649, A4253 and A4557 have a status indicator of "P" according to the Medicare Physician's Fee Schedule. Payment for these types of codes is always bundled into payment for other services, not specified, and no separate payment is made by Medicare.   Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the supplies provided to the enrollee on June 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the Myocardial perfusion imaging (78452), provided on August 17, 2021.  You asked the Plan to waive the copayment for the Myocardial perfusion imaging. You say that there should not me a cost share. The Plan denied your request. The Plan says the cost share 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 $200 copayment for each advanced imaging services for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $200 copayment for each advanced imaging services for the Myocardial perfusion imaging. This service 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 the Myocardial perfusion imaging (78452), provided on August 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on August 7, 2021.  You asked the Plan to pay for ambulance services. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered because the enrollee was in government custody.  The Plan must follow Medicare rules. Medicare rules say that Medicare's policy is to deny payment for items and services furnished to beneficiaries in State or local government custody.  We looked at the file and Medicare rules. The record shows that the enrollee was in government custody when the service at issue was rendered. Based on this information, we decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided on August 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on September 14, 2021.  You asked the Plan to pay for eyeglasses. You say that your eyeglasses were broken, and you could not see well enough without them to maintain your quality of life. You say your situation was an emergency. The Plan denied your request. The Plan says you received lenses on November 19, 2019 exhausting your eyewear benefit.  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. The Plan covers these services every 24 months.  We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on  November 19, 2019, which caused you to exhaust your eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic ultrasound provided on August 9, 2021.  You asked the Plan to pay for the diagnostic ultrasound. The Plan denied your request. The Plan says the services were provided out-of-network.  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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a diagnostic ultrasound provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on July 31, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like to appeal for a retroactive authorization based on medical necessity. 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 domiciliary or rest home visit (99336) provided on July 31, 2020 by an out-of-network (OON) provider.