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

We decided that the Plan does not have to waive the copayments for a specialist office visit and electrocardiogram (EKG) provided on March 30, 2021.

You asked the Plan to waive the copayments for the specialist office visit and the EKG. You say that you were advised that the Plan is covering all coronavirus expenses. The Plan denied your request. The Plan says you have been charged 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 $45 copayment for specialist services. 

The contract also clearly says that enrollees must pay a $30 copayment for outpatient diagnostic tests, including electrocardiograms (EKG's). 

You have been asked to pay a $45 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services Including Doctor's Office Visits benefit category. You have also been asked to pay $15.32, which is less than the $30 copayment for an electrocardiogram (EKG). EKG's fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The total for your visit is $60.32. Please note that the Plan's coronavirus temporary provisions say that there is no cost share waivers in effect for coronavirus treatment. 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 copayments for a specialist office visit and electrocardiogram (EKG) provided on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen (CPT code R0070) provided to the enrollee on July 8, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the provider reported transportation of portable radiology equipment but did not report setup codes which does not follow industry standard coding rules.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The provider reported transportation of portable radiology equipment but did not report setup codes, which does not follow industry standard coding rules. Transportation services are not reimbursable without the reporting of setup services. Diagnostic x-ray setup and transportation services were not performed by the portable x-ray provider. Therefore, we decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen (CPT code R0070) provided to the enrollee on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3346), resin-based composite (D2330), adjunctive procedure (D9999), and two office visits for observation (D9430 x2) provided from November 25, 2020 to December 14, 2020 by a Medicare opt out provider.
You asked the Plan to pay for the retreatment of previous root canal therapy, resin-based composite, adjunctive procedure, and office visits. You say that you paid for these services according to the instructions for the Plan and were told your Plan covers $1,000 annually. You also say you called several times and were assured you would be reimbursed but were not. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that this treating provider opted out of Medicare effective February 2, 2016, to February 2, 2022.
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, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy (D3346), resin-based composite (D2330), adjunctive procedure (D9999), and two office visits for observation (D9430 x2) provided from November 25, 2020 to December 14, 2020 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee surgery services coded as 27301 and 27487 provided on July 6, 2020.
You asked the Plan to pay for the knee surgery services. You say that these codes are supported in the medical documentation. The Plan denied your request. The Plan says the billed services are not supported in the medical records.
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 27301 is incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region. The CPT Code Manual definition of code 27487 is revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component. 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 knee surgery services. Our reviewer says that the documentation does not support the codes as billed. Our reviewer found that for CPT 27487, the operative report does not include enough information to confirm total knee revision was performed, to include femoral and tibial components are revised. Per operative report "The plastic was removed, it was 11 millimeters, without difficulty. We inserted a 16-milimeter trial was removed, the permanent plastic was inserted and was locked into place". In addition for CPT 27301, the documentation does not support an Incision and drainage as a separate procedure. Procedure was not performed on different organ, anatomic regions. 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 knee surgery services have not been met. Therefore, we decided that the Plan does not have to pay for the knee surgery services coded as 27301 and 27487 provided on July 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for CT, abdomen and pelvis; with contrast material(s) (CPT code 74177), gadobutrol, 0.1ML injection (CPT code A9585), and low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (CPT code Q9967) provided to the enrollee on March 17, 2021, by an out-of-network provider.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered for separate payment.  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, 71260 and 74177 both have a starting status indicator (SI) of Q3. They are from the same family and being performed on the same day. Therefore, 74177, A9585, and Q9967 are being packaged with 71260 and producing a Composite APC of 8006. 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 pay for CT, abdomen and pelvis; with contrast material(s) (CPT code 74177), gadobutrol, 0.1ML injection (CPT code A9585), and low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (CPT code Q9967) provided to the enrollee on March 17, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of thorax for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there were three outreach attempts to provider to obtain imaging with the long nodule diagnosis to help with this appeal and were unable to obtain records.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the only chest report in the records is from a computed tomographic angiography of the chest dated 10/30/20. That report mentions no pulmonary nodule whatsoever. Absent any further documentation of a pulmonary nodule requiring CT surveillance the medical necessity of CT of the chest has not been established. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of thorax for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite of one surface (D2391), resin-based composite of two surfaces (D2392), and resin-based composite of three surfaces (D2393) provided on June 7, 2021.
You asked the Plan to pay more for the resin-based composites. You say that this treating provider is not out-of-network. The Plan denied your request. The Plan says this claim has been processed in accordance with your plan benefit. The Plan also says that you are responsible for the coinsurance amounts that applied to these services, and no further reimbursement is due to you from the 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, you are responsible for a 50% coinsurance for each resin-based composite. Therefore, we decided that the Plan does not have to pay more for the resin-based composite of one surface (D2391), resin-based composite of two surfaces (D2392), and resin-based composite of three surfaces (D2393) provided on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair (K0823) and accessories (E2365, E09773, E1028).  

You asked the Plan to pre-approve a power wheelchair and accessories. You say that this is medically necessary.  The Plan denied your request. The Plan says this will not help the enrollee complete activities.  

The Plan follows Medicare rules. Medicare rules say that a power wheelchair is covered if use of a power wheelchair will significantly improve the beneficiary's ability to participate in mobility-related activities of daily living (MRADLs) and the beneficiary will use it in the home.  

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 power wheelchair and accessories. Our reviewer says that the requirements for coverage of the requested power wheelchair have not been met. Our physician reviewer found the enrollee will be unable to accomplish or participate in mobility-related activities of daily living with a power wheelchair. She receives constant custodial care in a group home. The requested wheelchair will not correct her functional deficits.  

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 power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0823) and accessories (E2365, E09773, E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 12, 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 service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on July 12, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667).
You asked the Plan to pre-approve the pneumatic compression device. You say that the pneumatic compression device is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a six-month trial of conservative therapy is required before a pneumatic compression device can be 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 pneumatic compression device. Our reviewer says that the requested device is not medically necessary. Our physician reviewer found the record does not show a six-month trial of conservative treatment including elevation and exercises. 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 pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary comprehensive cancer panel provided on March 7, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says screening genetic testing is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered for a specific medical problem.
We looked at the file and the rules. It appears that the test was ordered after a phone call with the enrollee to determine the enrollee's risk of cancer. Medicare does not cover this testing for screening purposes. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary comprehensive cancer panel provided on March 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services and procedures provided on
June 23, 2021.

You asked the Plan to pay for ophthalmological services and procedures. 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 ophthalmological services and procedures provided on
June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology testing services coded as 95957 and 95909 provided on February 16,2021.

You asked the Plan to pay for the neurology testing services. You say that the documentation supports the billed services. The Plan denied your request. The Plan says the records provided do not support the billed services.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 95909 is nerve conduction studies; 5-6 studies. The CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). 

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 neurology testing services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found that regarding CPT 95909, the technical report describes pedicle screw stimulation. This is the incorrect code to report for nerve conduction studies, as amplitude, latency and conduction velocity as measures. Regarding CPT 95957, the documentation does not support digital analysis of EEG, as "real time" monitoring is described. This is an inappropriate code to report for this procedure.

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 neurology testing services have not been met. Therefore, we decided that the Plan does not have to pay for the neurology testing services coded as 95957 and 95909 provided on February 16,2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90791) provided on August 13, 2021.
You asked the Plan to pay for psychotherapy services. You say that you had no clue that your visits with the provider at issue would not be covered. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90791) provided on August 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on February 14, 2021.
You asked the Plan to pay for the CT scan. You say that payment should be reconsidered. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The file shows that CPT code 70450 was billed with code 70496. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim provided, however, does not show that code 70450 was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on February 14, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 29, 2021.

You asked the Plan to pay for the 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 and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (CPT code 81162) provided to the enrollee on April 7, 2021.  

You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 81162 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on April 7, 2021, and received by the lab on April 8, 2021. Of note, the patient resides in Colorado (CO) and the billing laboratory is located in Utah (UT); therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 81162) provided to the enrollee on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for preventive evaluation and management services provided on June 2, 2021.

You asked the Plan to pay for the services provided. You say that you were not aware the provider was out-of-network. The Plan denied your request. The Plan says the billed code is not payable under Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99387 is a non-covered service. This service is not payable by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for preventive evaluation and management services provided on June 2, 2021.

Please note, the case file shows that you will not be held liable for charges related to code 99387. If the provider is billing you for charges, please contact the Plan directly.