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

We decided that the Plan does not have to reduce the copayment for the ultrasound examination of the heart provided March 17, 2021.
You asked the Plan to reduce the copayment for the ultrasound examination of the heart. You say that you believed this would be charged a $10 copayment as specified for lab work in the EOC. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $300 copayment for the ultrasound examination of the heart. This service falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. In addition, the Plan has confirmed that this was billed with a modifier to indicate that the location provided was an outpatient hospital which means the claim must be paid under the outpatient surgical benefit. 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 ultrasound examination of the heart provided 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 May 6, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the modifier code billed was not appropriate.

The Plan must follow Medicare rules. 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 99214 is office or other outpatient visit for the evaluation and management of an established patient. We find that code 99214 was billed with modifier 59. We looked at the file and the rules. Modifier 59 is not to be used for evaluation and management services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the bone replacement graft for ridge preservation (D7953) provided on May 19, 2021.

You asked the Plan to pay for the bone replacement graft. You say that you needed the bone graft after having your tooth extracted. You also say that you feel this procedure should be subject to the 50% coinsurance like the extraction was. The Plan denied your request. The Plan says that this service is not covered.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

The bone replacement graft was rendered by a contract provider. The file does not show that the Plan provided notice that the bone replacement graft would not be covered, or that the treating provider requested a prior authorization. Under Medicare rules, this means the bone replacement graft is considered approved by the Plan. The 2021 EOC does not show that a bone replacement graft for ridge preservation is clearly excluded from coverage, and only states that there is a maximum $2,500 allowance with 50% coinsurance every year for supplemental comprehensive dental services. Therefore, we decided that the Plan has to hold you harmless for the bone replacement graft for ridge preservation (D7953) provided on May 19, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the telehealth consultation provided on February 20, 2021 by an out-of-network provider.
You asked the Plan to pay for telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth (G0508). You say that services were rendered in an emergent circumstance. The Plan denied your request. The Plan says that the services were not urgent, emergent, nor 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 provider at issue in this case is not a network provider with the Plan. 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 pay for telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and providers via telehealth (G0508). Our reviewer says that the service was medically necessary. Our physician reviewer found in this case, the record indicates that the enrollee presented to the emergency room on February 20, 2021 as a stroke alert. Neurology evaluated the enrollee through a telemedicine consult. A stroke alert is an emergency situation. The elements of the coverage criteria are satisfied. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth (G0508) have been met. Therefore, we decided that the Plan has to pay for the telehealth consultation provided on February 20, 2021 by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.

You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records reviewed do not show a psychological evaluation.

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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the he records provided for review did not contain the records of a psychology screening/evaluation. The notes provided were only from internal medicine, neurology, and pain management. 

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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard wheelchair (K0001).

You asked the Plan to pre-approve a standard wheelchair. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage of a manual wheelchair have not been met.

The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. We requested additional medical records to support the medical necessity of the requested equipment. Without any medical records received, we cannot review to see if the services were urgent/emergent or medically necessary.

Based on this information, we decided that Medicare rules for coverage of a standard wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair (K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 12, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 the services provided on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (CPT code(s): 64636 and 64635), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show that the initial injection was only 70% effective and the second injection was not adequately evaluated.
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 services. Our physician reviewer found the criteria are not met. There is no clinical information on the outcome of the previous injection. More information is needed. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (CPT code(s): 64636 and 64635), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for programming device evaluation (in person) with iterative adjustment of the implantable device (93282) provided May 3, 2021.

You asked the Plan to waive the copayment for programming device evaluation. You say that you went to get your device checked, paid the $40 copay on your card and now you're being billed by the facility for $10. You are disputing the additional $10.00. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $10.00 copayment for Medicare covered outpatient diagnostic procedures or tests.

You have been asked to pay $10.00 copayment for the programming device evaluation. The programming device evaluation 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 programming device evaluation (in person) with iterative adjustment of the implantable device (93282) provided May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on February 10, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider type is not covered.

The Plan must follow Medicare rules. Medicare rules say that payment is made for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS). 

We looked at the file and Medicare rules. Review of the record shows that the provider is not a physician, PA, NP, or CNS. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.

You asked the Plan to pre-approve the requested services. You say that the enrollee has become less stable. The Plan denied your request. The Plan says the skills of a physical therapist are not needed.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 requested services. Our physician reviewer found that the enrollee has a diagnosis of Parkinson's disease. He has received 23 physical therapy visits. He is performing interval high intensity treadmill training. The requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the plan.

The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, of a qualified therapist are not required to establish, design and/or deliver a program to maintain his current condition or to prevent or slow further deterioration. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on May 4, 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 97530 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a special anesthesia service (code 99100) provided on October 28, 2020.

You asked the Plan to pay for special anesthesia service. 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 payment for this service is bundled into payment for other services and no separate payment is made per Medicare.

The Plan must follow Medicare rules. Medicare rules say that payment for code 99100 is always subsumed by the payment for the service to which it is incident. 

We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of special anesthesia service
have not been met. Therefore, we decided that the Plan does not have to pay for a special anesthesia service
(code 99100) provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device (E0675) and a pneumatic appliance (E0673) provided on February 16, 2021.
You asked the Plan to pay for the intermittent limb compression device and a pneumatic appliance. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of deep vein thrombosis.
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. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device (E0675) and a pneumatic appliance (E0673) provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office consultation rendered on February 9, 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 99245 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure code 99245 (office consultation) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the office consultation rendered on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on April 27, 2021.

You asked the Plan to pay for vision services. The Plan denied your request. 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 Plan says that the Plan has 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 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 vision services provided on April 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for low dose computerized tomography (LDCT) scan
You asked the Plan to waive the copayment for the diagnostic service. You say that you received a bill for $78.37 for a low dose CT scan. You have had this scan at no charge, for several years under the Medicare Part B lung cancer screening. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $75-$300 copay for diagnostic radiology services (not including x-rays) for CT scans, MRI's, myelography, PET scans, MRA, SPECT, CTA, nuclear cardiology and stress tests. You have been asked to pay $78.37 for the diagnostic service. Since the allowed amount falls within the copayment amount, you are responsible for the allowed amount. The diagnostic service 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 low dose computerized tomography (LDCT) scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug tests provided on December 7, 2020.
You asked the Plan to pay for the drug testing. You say that this should be covered. The Plan denied your request. The Plan says this is not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly. We looked at the file and Medicare rules. The documentation does not support that POS code 81 is correct as it is not supported that the sample was taken directly by the lab. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug tests provided on December 7, 2020.