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

We decided that the Plan does not have to waive the copayment for skin debridement provided by a network facility on October 5, 2021.

You asked the Plan to waive the copayment for the skin debridement. You say that you disagree with the $350 copayment you are being charged for the outpatient procedure. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment per date of service at an outpatient hospital facility. 

The enrollee has been asked to pay a $350 copayment for the skin debridement. The skin debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.

This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for skin debridement provided by a network facility on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the chiropractic services rendered on September 29, 2021 to October 4, 2021.

You asked the Plan to pay for these services. You say that the provider told you that everything was covered. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The 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.

Review of the file shows that you received Coronavirus supplies from the out-of-network chiropractor on September 29, 2021 to October 4, 2021. These services are not covered by Medicare or your supplemental chiropractic benefit with the Plan. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on September 29, 2021 to October 4, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the lab services (88189) provided on September 22, 2021.  

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that these services were billed by another provider on the same date of service.  

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The documentation submitted does not show that these services were provided by another provider on the date of service in question. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the lab services (88189) provided on September 22, 2021.   

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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 1, 2021.  

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you went to have your front tooth repaired because it broke, and the dentist advised you not to have it repaired because it would continue to break. You also say that you thought when you went to the dentist for a problem, they have to evaluate you to fix the problem. The Plan denied your request. The Plan says this service is not covered.  

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. The only types of exams covered under your benefit are routine oral exams and comprehensive oral exams. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health services rendered on April 20, 2021 to August 10, 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 procedure codes 96156 is 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 96156 (health behavior assessment or re-assessment) and 99214 (office visit). Code 96516 is a column II code with a modifier indicator of 1 when billed with column I code 99214. Code 96156 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 outpatient mental health services rendered on April 20, 2021 to August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision services (92133, 92014) provided on July 12, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for out-of-network vision care. You say that you have seen this provider for years, even before you had this insurance. You trust this provider and see them about once per year. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The services at issue were not urgent or emergent, nor were they pre-approved.  

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 vision services (92133, 92014) provided on July 12, 2021, by an out-of-network (OON) provider.
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 November 13, 2021.

You asked the Plan to pay for the ambulance service. You say that you are a former rescue squad member. You say that you were aware that the treatment you needed was available on ambulances in your area in recent years. You say that you would be happy to pay the $225 copayment for ambulance services. You also say that if you had gone to the hospital, your copayment would have been much more. 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 no transport was 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 November 13, 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 November 13, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing services provided from July 9, 2021, to July 11, 2021, and from July 16, 2021, to August 7, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable medical records for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the skilled nursing services provided from July 9, 2021, to July 11, 2021, and from July 16, 2021, to August 7, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (procedure code 99204) provided to the enrollee on September 20, 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 this needs to be re-billed with the correct 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, the CPT Code Manual definition of code 99204 is "Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter." 

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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found based on the records provided, it was not appropriate to bill the visit at a new patient. You had a prior visit on 6/7/21 with the same practice group within the three year period defined by the guidelines. 

We looked at this coder'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 an office visit (procedure code 99204) provided to the enrollee on September 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on September 13, 2021.  

You asked the Plan to waive the copayment for an ultrasound. You say that the ultrasound was a necessary diagnostic service. 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 $165 copayment for radiological diagnostic services.     

You have been asked to pay the allowed amount of $106, which is less than the $165 copayment for an ultrasound. An ultrasound 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 ultrasound provided on September 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuromonitoring services (95938, 95957, 95907, 95887, 95885) provided October 6, 2020. 

You asked the Plan to pay for the neuromonitoring services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not eligible for separate payment.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code 95938, 95957, 95907, 95887, and 95885 is not supported in the medical record.      

Specifically, the services billed have a professional component / technical component of 1 and are not eligible for separate payment at the place of service billed. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95938, 95957, 95907, 95887, 95885) provided October 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lucentis.  

You asked the Plan to pre-approve Lucentis. The Plan denied your request. The Plan says the step therapy criteria have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  

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 Lucentis. Our reviewer says that Avastin is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drug bevacizumab (Avastin) before they will approve the requested drug. In this case, the the enrollee has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 14, 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 this claim was submitted with an inappropriate place of service code.  The Plan must follow Medicare rules. 

Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was billed with the laboratory place of service code while the record suggests that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on September 8, 2021.  

You asked the Plan to waive the copayment for the CT scan. You say that the abdomen scan was free and you do not know why you are being charged for a second scan. The Plan denied your request. The Plan says you have been 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 $195 copayment for diagnostic and nuclear medicine radiological services, including CT scans. If multiple tests of the same type are performed in the same day, only one copayment will apply.   

You have been asked to pay a $195 copayment for the CT scan. The CT scan 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 computed tomography (CT) scan of the abdomen and pelvis provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on September 29, 2021.

You asked the Plan to waive the deductible for the laboratory services. You say that you do not understand why you have to pay two-thirds of the bill. The Plan denied your request. The Plan says the correct amount was applied to your deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $300 in-network deductible which applies to certain items and services. 

The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 in-network deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the laboratory services was received on September 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480, 80307) provided on August 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you were not aware of the requirement of obtaining a prior authorization, specifically for this member's plan type at the time of rendering services and you conducted in good faith the laboratory testing ordered by the referring provider, who deemed the services medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan also says that this service was not an ambulance service, emergency and urgently needed, post stabilization care, nor dialysis while outside of the service area. The Plan also states that both the referring and attending providers are all non-participating with the Plan.

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 drug testing (G0480, 80307) provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and an intraoral radiographic image (D0220) provided by a participating provider on October 12, 2021.  

You asked the Plan to pay for a limited oral evaluation and an intraoral radiographic image. You say that you were not aware that these services were not covered. The Plan denied your request. The Plan says the rendered dental work 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 a limited oral evaluation (D0140), and an intraoral radiographic image (D0220) provided by a participating provider on October 12, 2021.