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

We decided that the Plan does not have to pay for CT of the head or brain (70450) provided on May 17, 2021.

You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says a National Correct Coding Initiatives Procedure to Procedure edit exists between CPT codes 70450 and 70496.

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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Of note, a modifier has not been billed to indicate that this service is separate and distinct. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for CT of the head or brain (70450) provided on May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95861) provided April 29, 2021.

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 a valid diagnosis code was not billed on this claim.

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 95861 is not supported in the medical record. Specifically, per Local Coverage Article:
Billing and Coding: Nerve Conduction Studies and Electromyography (A57668), diagnosis code M53.3 is not a
valid diagnosis code for the services at issue. 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 (95861) provided April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health services provided March 23, 2021, to March 31, 2021.

You asked the Plan to waive the copayment for the inpatient mental health services. You say that you don't agree with the cost-share applied to the enrollee's inpatient stay. The Plan denied your request. The Plan says the copayment was applied correctly. Additionally, the Plan notes that the enrollee is not responsible for the cost for the unapproved days of the inpatient stay.

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 $200 copayment for Day 1 and a $25 copayment for each day, Days 2-5 for an inpatient hospital stay.

The enrollee has been asked to pay a total of $300 ($200 copayment for day 1 and a $25 copayment for each day days 2-5) for the inpatient mental health services. This service falls within the Inpatient mental health care 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 the inpatient mental health services provided March 23, 2021, to March 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on May 17, 2021.

You asked the Plan to pay for non-emergency transportation, wheelchair van. The Plan denied your request. The Plan says wheelchair van (chair car) transportation is not covered by Medicare even if provided by an ambulance company.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van (A0130) provided on
May 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy with a biopsy (43239) provided on April 12, 2021.

You asked the Plan to waive the copayment for the endoscopy procedure. You say that this service is medically necessary, and you feel it should be covered in full. The Plan denied your request. The Plan says this claim was processed correctly, and this service is covered. You are responsible for your share of the cost as indicated in your contract.

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 $350 copayment for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. 

You have been asked to pay a $350 copayment for the endoscopy procedure. The endoscopy procedure falls within the outpatient procedures and services benefit category and was performed in an outpatient hospital or ambulatory surgical center. 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 endoscopy with a biopsy (43239) provided on April 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy with specimen collection
(43235) and sigmoidoscopy (45334) provided on June 3, 2021.
You asked the Plan to waive the copayment for the endoscopy services. You say that you had a previous
service at this clinic without a copay and feel you should not have a copay for these services. The Plan denied
your request. The Plan says this claim was processed correctly, and your share of the cost was assessed in
accordance with your contract. The Plan also says that this is a difference service than the one you previously
had at this clinic.
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 $245
copayment for outpatient surgery provided at an ambulatory surgical center.
You have been asked to pay a $245 copayment for the endoscopy services. The endoscopy services are
classified as a surgical procedure, and in this case, they were provided in an ambulatory surgical center. 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 endoscopy with specimen collection (43235) and sigmoidoscopy (45334) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on
March 30, 2021.

You asked the Plan to reimburse you for the eye exam and eyeglasses. The Plan denied your request. The Plan says vision services must be obtained from a provider in the Plan's vision vendor network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network. 

We looked at the file and the Plan's rules. The file shows that the eye exam and eyeglasses were not obtained from a provider in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator garment
(K0606) provided on March 29, 2021.

You asked the Plan to waive the coinsurance for an automatic external defibrillator garment. You say that you
were never made aware of your cost-sharing responsibility. The Plan denied your request. The Plan says the
correct coinsurance was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for each Medicare-covered item of durable medical equipment.

You have been asked to pay $560, or 20% of the Medicare-allowed charge of $2,800, for an automatic external
defibrillator garment. An automatic external defibrillator garment falls within the "Durable medical equipment
(DME) and related 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 coinsurance for an
automatic external defibrillator garment (K0606) provided on March 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0425, A0429) provided on February 10, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you felt the paramedics who arrived with the ambulance were rude and unprofessional. You do not feel that you should have to pay this copayment because the staff tried to tell you that you did not need to go to the hospital by ambulance and you received no help with getting into the vehicle and were not provided medical attention on scene. You were diagnosed with COVID at the hospital. The Plan denied your request. The Plan says this claim was covered and processed correctly. Your cost-sharing amount was assessed in accordance with your contract.

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 $300 copayment for each Medicare-covered ambulance trip.

You have been asked to pay a $300 copayment for the ambulance transportation. 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 emergency ambulance transportation services (A0425, A0429) provided on February 10, 2021.

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. the QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for the hydration therapy rendered on May 14, 2020. 
 
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 that the services are not covered. 
 
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 states that the services were rendered in the state of New Jersey and 
that Local Coverage Determination (LCD) L34960 is binding; however, there is no documentation in the file to 
support that the services were rendered in New Jersey. The claim dispute form lists a National Provider 
Identifier (NPI) number that is listed as located in New York. The Plan has not provided any further 
documentation or rules to support that the services are not payable. Therefore, we decided that the Plan has to 
pay for the hydration therapy rendered on May 14, 2020.  
 
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 injections (64494) provided October 5, 2020.

You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.

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 64494 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 the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64494) provided October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (99203) provided on May 18, 2021.

You asked the Plan to pay for the non-covered chiropractic services (99203). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says office visit services with code 99213 are not covered when provided by a chiropractor.

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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services (99203) provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive hearing loss genetic panel (81324, 81325, 81407) provided on February 22, 2021.

You asked the Plan to pre-approve a comprehensive hearing loss genetic panel. You say that this should be covered. The Plan denied your request. The Plan says this was performed as a screening.

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, a comprehensive hearing loss genetic panel, is being 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 pre-approve a comprehensive hearing loss genetic panel (81324, 81325, 81407) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials rendered on November
12, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.

We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and clinical staff time) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials rendered on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.
You asked the Plan to pay for intermittent limb compression device. You say that the physician prescribed this device because they felt it was necessary for the medical safety of the enrollee. You feel that you should be compensated for the services received. The Plan denied your request. The Plan says pneumatic compression devices and supplies are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided on January 5, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided March 22, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the  billed 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.

You asked the Plan to pre-approve Keytruda. You say that the enrollee has had disease progression and received previous treatment. The Plan denied your request. The Plan says that this drug is not being prescribing for a medically-accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee. Keytruda is not FDA-approved as first line therapy for the enrollee's diagnosis. The patient has received prior therapy for other cancers not for sarcoma. The use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
18, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a specialist office visit on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $45 
copayment for services obtained from a specialist.  

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist 
office visit on May 18, 2021. You have been asked to pay a $45 copayment for the specialist office visit. The 
specialist office visit falls within the Physician/Practitioner 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 specialist office visit provided on May 18, 2021.