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

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable and necessary for the enrollee's condition. 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 the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed before this service can be approved.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have waive the cost sharing amount for the myocardial perfusion imaging, tomographic (78452), technetium tc-99m sestamibi, diagnostic, per study dose (A9500), cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress (93015), and adenosine injection (J0153) provided on June 2, 2021.  You asked the Plan waive the cost sharing amount for the nuclear stress test. You say that you were advised multiple times that you would be responsible for a $110 copayment. You say that the services should be covered. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the cost share amounts were applied correctly. The Plan also says cost share is a contractual obligation of the plan and cannot be waived.  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 $110 copayment for radiological diagnostic services, $20 copayment for non-radiological diagnostic services, 20% coinsurance for Medicare-covered medical supply benefit, and 20% coinsurance for Medicare Part B prescription drug.   You have been asked to pay $110 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the radiological diagnostic services benefit category.  You have been asked to pay $20 copayment for the cardiovascular stress test. The cardiovascular stress test falls within the non-radiological diagnostic services benefit category.  You have been asked to pay 20% coinsurance for the technetium tc-99m sestamibi. The technetium tc-99m sestamibi falls within the Medicare-covered medical supply benefit category. You have been asked to pay 20% coinsurance for the adenosine injection. The adenosine injection falls within the Medicare Part B prescription drug 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 waive the cost sharing amount for the myocardial perfusion imaging, tomographic (78452), technetium tc-99m sestamibi, diagnostic, per study dose (A9500), cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress (93015), and adenosine injection (J0153) provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on September 23, 2021.  You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you disagree with the charges and being billed as if you received the services outside of the providers office. 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 $125 copayment for ultrasounds.   You have been asked to pay a $125 copayment for an ultrasound of the heart. An ultrasound of the heart 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 of the heart provided on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation services you received from October 30, 2019, to November 19, 2019.  You asked the Plan to waive the copayment for the acute inpatient rehabilitation services. You say that you were never provided a detailed statement explaining this charge. You say that you were never told you were being discharged and readmitted, just that you were changing rooms in the hospital.  You said that had you been told about this, you would have considered not changing rooms. You said that this was one continuous stay. 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 $310 copayment per day for days 1-6 for inpatient hospital services.   Records show that you were admitted to a regular acute care hospital bed on October 25, 2019.  You remained there until October 30, 2019.  You paid an inpatient hospital copayment for this stay, and this is not in dispute.  On October 30, 2019, you were discharged from the acute care portion of the facility and readmitted to the acute inpatient rehabilitation portion of the facility.  You were placed in a different room.  You have been charged a second copayment for this acute inpatient rehabilitation stay. You have been asked to pay a $310 copayment per day for days 1-6 (for a total of $1860) for the acute inpatient rehabilitation services.   Your Evidence of Coverage explicitly states that inpatient benefits will begin on the first day you are admitted or transferred to an inpatient acute facility, inpatient rehab, or long-term acute care facility.  The cost-sharing for inpatient hospital benefits applies each time you are admitted to one of these facilities. When you transferred from the acute portion of the hospital to the inpatient rehabilitation portion of the hospital, you were effectively discharged and readmitted to a different facility (even if it is under the same roof). Because this is considered a new admission, a second copayment can apply. 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 acute inpatient rehabilitation services you received from October 30, 2019, to November 19, 2019.   Your complaint about not receiving a detailed statement from the facility or the Plan 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this 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 the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex devcie is experimental. More research is needed before coverage can be approved.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the item is medically necessary. The Plan denied your request. The Plan says you are not insulin treated.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 9, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the clinical social worker will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up office visit and eye testing to be rendered by the out-of-network (OON) providers.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested providers in this case are not network providers with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a follow-up office visit and eye testing to be rendered by the out-of-network (OON) providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided by a network provider on October 18, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that you asked for the full routine eye exam that is fully covered. You say they did not do anything medical. 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). Your contract with the Plan clearly says that you must pay a $35 copayment for a medical eye exam.

You have been asked to pay a $35 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows diagnoses for cataracts and drusen which means the visit is considered medical.

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 medical eye exam provided by a network provider on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the simple extraction (D7140) and problem focused limited oral evaluation (D0140) provided on September 14, 2021.  You asked the Plan to pay for the simple extraction and problem focused limited oral evaluation. You say that you would like to appeal these services. The Plan denied your request. The Plan says simple extraction is not a covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan.  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, simple extraction (D7140) is not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on March 23, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the simple extraction (D7140) and problem focused limited oral evaluation (D0140) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 99053 provided on July 2, 2020.

You asked the Plan to pay for the medical services as billed. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment can be made for these services according to Medicare coding regulations.

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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.

We looked at the file and Medicare rules. In this case, the billed code has a Status Indicator of "B" under the Physician's Fee Schedule. This means that payment for covered services is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99053 provided on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a cystourethroscopy provided on January 19, 2021.  You asked the Plan to waive the coinsurance for a cystourethroscopy. You say that you were charged much less for the same service on another date. 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 20% coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   The record shows that you received a cystourethroscopy at an outpatient hospital facility on January 19, 2021. A cystourethroscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay $624.45, which is less than the 20% coinsurance amount.   You have been asked to pay the total amount of $624.45 for a cystourethroscopy. A cystourethroscopy falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 a cystourethroscopy provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 25320 and 64719 provided on June 2, 2021.  You asked the Plan to pay for the medical services as billed. You say that these services were billed correctly. The Plan denied your request. The Plan says the documentation does not support payment for the services 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. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    In this case, the CPT Code Manual definition of code 25320 is Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability. The CPT Code Manual definition of code 64719 is Neuroplasty and/or transposition; ulnar nerve at wrist.  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 medical services as billed. Our reviewer says that the documentation does not support payment for the services as billed. Our reviewer found the medical records provided do not include sufficient documentation the validate that a 25320 LT - Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft (includes synovectomy, capsulotomy and open reduction) for carpal instability was performed on June 2, 2021. Therefore, this procedure cannot be verified.    Furthermore, CPT 64719-59 has a bundled relationship with CPT 64721, which was also performed on June 2, 2021; however, an approved modifier is allowed to be used to unbundle these services, providing the medical records support the use of an appropriate modifier. In this case. the medical records submitted does not support the use of modifier 59, therefore no additional reimbursement is allowed.  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 medical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 25320 and 64719 provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on September 20, 2021.  You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier to bypass the 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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (01936) provided on September 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for anesthesia services. You say that you are appealing with supporting records.  The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent nor were they approved in advance.  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 anesthesia services (01936) provided on September 16, 2021, by an out-of-network (OON) provider.