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

 We decided that the Plan does not have to pay for an x-ray (71045) provided on August 9, 2021.  You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not separately payable.  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 71045 is a column II code to column I code 71046. 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 an x-ray (71045) provided on August 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on September 8, 2021.     You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told the colonoscopy was covered unless polyps were removed. You say no polyps were removed and you should not have a copayment. 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 $290 copayment for each Medicare-covered in-network outpatient hospital facility visit.   You have been asked to pay a $290 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows polyp removals in all previous colonoscopies which makes this colonoscopy diagnostic in nature.  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 provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 19, 2021.  You asked the Plan to pay an additional amount for eyeglasses. You say that you thought the upgrades would be covered and you could afford the extra cost. The Plan denied your request. The Plan says if the eyewear purchase costs more than the allowance applicable to your plan, the member is responsible to pay the difference.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan has paid the eyewear allowance applicable to your Plan and you are responsible to pay the difference. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 19, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency care provided June 27, 2021.  You asked the Plan to pay for emergency care. You say that you have not received any payment for this claim. The Plan denied your request. The Plan says another insurance carrier has confirmed that there is coverage. The Plan does not have a copy of the payment log from the alternate insurance carrier.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the primary payer and directed the provider to contact the primary payer. As the secondary insurer, the Plan cannot be held responsible for emergency care until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for emergency care provided June 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transport rendered on August 24, 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 the claim was not billed correctly.  The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.  We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport rendered on August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the physical therapy assessment shows that it would not be safe for a patient to go to skilled nursing or have home physical therapy and the enrollee needs to go to a rehabilitation hospital. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for total knee replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the remaining unit of CPT code 64624 provided on March 17, 2021.  You asked the Plan to pay for the remaining unit of CPT code 64624. You say that CPT code 64624 requires the destruction of the superolateral, superomedial and inferomedial nerve branches. You say that the operative report shows proof the patient has services on three nerves. The Plan denied your request. The Plan says the third unit remains denied as only 2 units are allowed and were paid.  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 64624 is 2. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE. The Plan paid for 2 units. Based on this information, we decided that Medicare rules for coverage of the remaining unit of CPT code 64624 have not been met. Therefore, we decided that the Plan does not have to pay for the remaining unit of CPT code 64624 provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on September 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you were told by your insurance agent that there would be no changes to your medical care by accepting this insurance plan. 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 September 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 the x-ray exam of the ribs (71101), the set-up of portable  x-ray equipment (Q0092), and the transportation of portable x-ray equipment (R0070) rendered by the out-of-network (OON) provider on July 18, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 the x-ray exam of the ribs (71101), the set-up of portable x-ray equipment (Q0092), and the transportation of portable x-ray equipment (R0070) rendered by the out-of-network (OON) provider on July 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) coded 95957, the nerve conduction studies coded 95908, and the needle electromyography services coded 95886 provided on April 19, 2021.  You asked the Plan to pay for the digital analysis of electroencephalogram (EEG), the nerve conduction studies, and the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 codes 95957, 95908, and 95886 are not supported in the medical record. Specifically, technical report did not include documentation of a digital analysis of electroencephalogram (EEG) (for epileptic spike analysis); therefore, code 95957 cannot be verified. The technical report did not include documentation of nerve conduction studies; for 3-4 studies; therefore, code 95908 cannot be verified. The technical report did not include documentation of a complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure); therefore, code 95886 cannot be verified.   Based on this information, we decided that Medicare rules for coverage of the digital analysis of electroencephalogram (EEG), the nerve conduction studies, and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) coded 95957, the nerve conduction studies coded 95908, and the needle electromyography services coded 95886 provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids, digital, binaural, BTE (V5261) purchased May 17, 2021, from an out-of-network provider.  You asked the Plan to pay for the hearing aids. You say that the information in the ANOC 2021 says there is a $500 allowance per year. There was no information that you needed prior approval or that the provider was not an approved vendor. You would like to be reimbursed the $500. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider.    Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from an in-network vendor.   We looked at the file, and the Plan's rules.  The rendering 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. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, digital, binaural, BTE (V5261) purchased May 17, 2021, from an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for individual psychotherapy services (90837) provided August 18, 2021.  You asked the Plan to pay for the psychotherapy services. You say that the medical records provided support the necessity of the service in dispute. The Plan denied your request. The Plan says that the service is not supported without the required documentation.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for individual psychotherapy services (90837) provided August 18, 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on August 31, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $90 copayment for each emergency care service.     You have been asked to pay a $90 copayment for the emergency care service provided. 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 room visit (99285) provided on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Myopro.  You asked the Plan to pre-approve Myopro. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.  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 Myopro. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a stroke in March 2021 and has left upper extremity paralysis. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Therefore, the enrollee does not meet criteria for the requested device.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myopro have not been met. Therefore, we decided that the Plan does not have to pre-approve Myopro.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services rendered on June 18, 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 code 99152 is not supported.  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, there is no documentation of an initial 15 minutes of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) and limited oral evaluation - problem focused (D0140) provided July 29, 2021.  You asked the Plan to pay for the adjunctive pre-diagnostic test and limited oral exam. You say that the provider is the only oral surgeon in your village. The Plan denied your request. The Plan says these services are not covered because the provider has opted out of Medicare.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the adjunctive pre-diagnostic test and limited oral exam when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare.  We looked at the file and Medicare rules. In this case the provider who rendered the services at issue has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the adjunctive pre-diagnostic test and limited oral exam have not been met. Therefore, we decided that the Plan does not have to pay for adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures (D0431) and limited oral evaluation - problem focused (D0140) provided July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on September 15, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 the laboratory services rendered by the out-of-network (OON) provider on September 15, 2021.