Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on November 13, 2020 by an out-of-network provider.
You asked the Plan to pay for destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic (64633, 64634) and Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) (20552). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider did not obtain prior authorization as required.
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 services at issue in this appeal. 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 pain management services provided on November 13, 2020 by an out-of-network provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic enema (74283) provided on April 26, 2021.

You asked the Plan to pay for the therapeutic enema. You say that procedure code 74283 was not bundled with any other procedure code performed on the same date of service. You say that the medical records should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.

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 74283 has a bundled relationship with code 74270 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 therapeutic enema (74283) provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician and laboratory services provided on June 17,
2020.
You asked the Plan to pay for the physician and laboratory services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as
billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate
claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of
service, type of service, procedure code, place of service and billed amount for codes 99213, 17004, 11102, and
11103.
The file also shows the CLIA number was missing from the claim billed on the ASC x12 837 professional
format. Code 80305 is not payable with this number missing from the claim. Therefore, we decided that the
Plan does not have to pay for the physician and laboratory services provided on June 17, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance angiography (MRA) represented by code 70544 and the computed tomography (CT) scan represented by code 70450 provided on February 7, 2021.
You asked the Plan to pay for codes 70544 and 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate line item. We have also 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. 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 Magnetic resonance angiography (MRA) represented by code 70544 and the computed tomography (CT) scan represented by code 70450 provided on February 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit provided on March 15, 2021.
You asked the Plan to pay for the chiropractic office visit (99203). You say that you want the Plan to pay for the service since the doctor said it was necessary due to being a new patient. The Plan denied your request. The Plan says only manual manipulation of the spine to correct subluxation is 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 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 chiropractic office visit provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the methadone treatments provided on March 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the methadone treatments. You say that you did not know that an authorization was required for an out-of-network provider. You are asking for the claim to be processed. 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. Therefore, we decided that the Plan does not have to pay for the methadone treatments provided on March 6, 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 moderate sedation services represented by code 99152 provided on March 5, 2021.

You asked the Plan to pay for code 99152. 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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not contain evidence that moderate sedation was performed with the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99152 provided on March 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation you received on June 15, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay for this service because the ambulance staff dropped you. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that because the allowed amount for this transport ($182.69) is less than your copayment obligation, you are responsible for the full allowed 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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for the ambulance transport. This copayment applies regardless of your satisfaction with the ambulance 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 ambulance transportation you received on June 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care provided on November 27, 2019.
You asked the Plan to pay for the emergency department visit (99285) and electrocardiogram (93010). You say that the enrollee gave you the wrong insurance information. The Plan denied your request. The Plan says the claim was untimely.
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 emergency department visit (99285) and electrocardiogram (93010) was not filed until March 22, 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 emergency care provided on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on April 27, 2021.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that your agent told you the dentist was in-network and your cleaning would be covered. You say that you would not have gone if you knew he did not participate, and you do not feel responsible for this charge since you were misinformed. The Plan denied your request. The Plan says the dentist is excluded from rendering services under Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on April 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the occupational therapy evaluation you had at an outpatient hospital facility on March 18, 2021.
You asked the Plan to reduce the copayment for the occupational therapy evaluation. You say that you were told that occupational therapy was only $20 per session. You said that even though you need more therapy, you cannot afford more than $20 per session. The Plan denied your request. The Plan says you were charged this copayment 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 occupational therapy you receive at an outpatient hospital facility.
You have been asked to pay a $150 copayment for the occupational therapy evaluation. Because this service occurred at an outpatient hospital facility, the outpatient hospital services copayment of $150 applies. 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 reduce the copayment for the occupational therapy evaluation you had at an outpatient hospital facility on March 18, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on April 12, 2021.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you have never been charged for an ultrasound before. The Plan denied your request. The Plan says you were charged this copayment 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 $110 copayment for diagnostic radiology services. You have been asked to pay a $110 copayment for the breast ultrasound. The breast ultrasound falls within the diagnostic radiology 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 breast ultrasound you had on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work, the chest x-ray, and the ECG provided on June 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work, the chest x-ray, and the ECG. You say that Medicare is supposed to pay for 80% of the claims. You say your doctor refused to offer a referral. 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. Therefore, we decided that the Plan does not have to pay for the laboratory work, the chest x-ray, and the ECG provided on June 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 office visit provided on May 7, 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 services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 7, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-Ray examination (74018) provided on April 26, 2021.

You asked the Plan to pay for 74018. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because codes 74018 and 74270 have a procedure-to-procedure (PTP) edit modifier of 1 which means that payment may be made for this code pair with an appropriate modifier, but an appropriate modifier was not billed on this code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 74018 has a bundled relationship with code 74270 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed with this code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an X-Ray examination (74018) provided on April 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport you received on February 25, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford this amount. The Plan denied your request. The Plan says you were charged this copayment 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 ambulance services. You have been asked to pay a $150 copayment for the ambulance transport. 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 transport you received on February 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thread superficial peroneal nerve release procedure.

You asked the Plan to pre-approve a thread superficial peroneal nerve release procedure. You say that this requested procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a thread superficial peroneal nerve release procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. Therefore, the request is considered 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 a thread superficial peroneal nerve release procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a thread superficial peroneal nerve release procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45378) provided on June 23, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were first given an alternative to a screening which has a high false positive rate. Then you had to have a second exam which turned up nothing and are upset you have to pay this copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment 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 $175 copayment for a diagnostic colonoscopy provided at an ambulatory surgical center. You have been asked to pay a $175 copayment for the diagnostic colonoscopy. The colonoscopy service was billed as a diagnostic procedure and was 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 diagnostic colonoscopy (45378) provided on June 23, 2021.
Your complaint about the care you were directed to receive from a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 3, 2021.

You asked the Plan to pay for the services provided. You say that the modifier is required according to Medicare guidelines. The Plan denied your request. The Plan says the claim is not reimbursable according to billing guidelines.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. The service at issue was billed with a -QL modifier. The records provided indicate emergency medical services were activated for obvious death. The records do not indicate the enrollee died after the ambulance had been called, but before the ambulance arrived. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on April 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
January 17, 2021, to January 27, 2021.
You asked the Plan to pay for home health services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, a required
"G" code to describe the type of service provided was not listed on the claim. Therefore, we decided that the
Plan does not have to pay for the home health services provided to the enrollee from January 17, 2021, to
January 27, 2021