Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on April 9, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken and the code should be reprocessed for prompt payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 3, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 drug testing coded G0483 provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the office visit provided on April 20, 2021.

You asked the Plan to pay for the office visit (99204). You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says that the claim cannot be paid because the provider did not request prior authorization.

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. 

You were referred for the office visit (99204) by a contract provider. The file does not show that the Plan provided notice that the office visit (99204) would not be covered. Under Medicare rules, this means the office visit (99204) is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the office visit provided on April 20, 2021.

If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on March 28, 2021 and March 31, 2021.

You asked the Plan to waive the copayments for the ambulance rides. You say that you were unaware of the high copayment amount and cannot pay this. 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 $250 copayment for Medicare-covered ambulance services. Cost sharing applies for each one-way trip.

You have been asked to pay a $250 copayment for the ambulance rides on each date of service. The ambulance rides fall within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ambulance rides provided on March 28, 2021 and March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on February 19, 2021 by an OON provider.
You asked the Plan to pay for the retroperitoneal ultrasound. You say that your primary care provider would not do a referral because the ultrasound was ordered by a specialist. The Plan denied your request. The Plan says this service was rendered by a non-participating provider, and the service was not referred by a participating provider. The Plan also says that this service was not 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on February 19, 2021 by an OON provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on June 22, 2021.

You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you were told there would be no charge for an endoscopy. 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 $120 copayment for each covered visit to an in-network ambulatory surgical center.

You have been asked to pay a $120 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facility and ambulatory surgical center" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials provided on February 5, 2021.

You asked the Plan to pay for the additional supplies and materials. You say that the medical records fully support and justify billing code 99072. You say that the daily notes clearly show the kind of precautions taken and the code should be reprocessed for prompt payment. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam - four or more surfaces, primary or permanent (D2161) provided April 13, 2021.
You asked the Plan to pay for the amalgam. You say that you had an issue getting an appointment due to the pandemic which caused you to need 3 amalgams in 2021. The Plan denied your request. The Plan says you have exceeded the frequency limit for the requested service.
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 two amalgams per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that two amalgams were previously covered on April 6, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the amalgam has been exceeded. Therefore, we decided that the Plan does not have to pay for the amalgam - four or more surfaces, primary or permanent (D2161) provided April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.

You asked the Plan to provide therapeutic continuous glucose monitor system (K0553, K0554). You say that the enrollee needs a CGM. The Plan denied your request. The Plan says there is no indication of an insulin regimen, blood glucose levels or an in-person visit with the provider to evaluate glucose control.

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, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, or has had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor system (K0553, K0554) have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this technique is unproven and 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglass frames (V2020) and progressive lenses (V2781).

You asked the Plan to pre-approve eyeglass frames and progressive lenses. You say that you have been having serious migraines due to the change in your vision and your doctor recommended new glasses. The Plan denied your request. The Plan says you are not eligible for glasses till October 15, 2021.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you receive a $275 allowance towards the purchase of eye wear including eyeglass frames and lenses, every two years. 

We looked at the file and the Plan's rules. The records show that you last used your benefit allowance on October 14, 2019. The EOC confirms you receive an allowance benefit for glasses and lenses every two years, therefore, you will be eligible for new frames and lenses on October 15, 2021. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglass frames (V2020) and progressive lenses (V2781) provided by The Nationwide Vision Store.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on March 29, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told multiple times that the provider was in-network. 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 in-network DME and related supplies, and 30% coinsurance for out-of-network DME and related supplies.

You received DME and related supplies on March 29, 2021, from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $55.90 and 30% of that is $16.77. 

You have been asked to pay the total coinsurance amount of $16.77 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 28,
2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay
the copayment because your surgery failed. The Plan denied your request. The Plan says the copayment you are
being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment per day, for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says that
you pay a $0 copayment for days 6 to 90 for inpatient hospital care.
You have been asked to pay a $150 copayment per day for inpatient hospital care. The records show you were
in inpatient care for one day. The EOC confirms $150 is the required copayment for this service. 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 inpatient hospital care provided on May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for suture of mesentery (44850) provided February 6, 2021.
You asked the Plan to pay for suture of mesentery. You say that you would like this claim reprocessed based on the cited modifier. The Plan denied your request. The Plan says there are no modifiers allowed with this code pair and the claim has denied correctly.
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 suture of mesentery has a bundled relationship with code 44160 and cannot be paid as billed. This code cannot be paid as a separate line item regardless of what modifier is used. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for suture of mesentery (44850) provided February 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the H200 wireless functional electrical stimulation (FES) orthosis (E0770) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the orthosis. You say that you strongly disagree with the conclusion and requests for reconsideration of this determination. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. This device is experimental and investigational in the treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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. 

In this case, this device is being requested to treat diffuse traumatic brain injury with loss of consciousness greater than 24 hours. The enrollee does not meet the criteria as the enrollee does not have a spinal cord injury nor does he have muscle atrophy noted in the records. The requested provider in this case is not a network provider with the Plan. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the H200 wireless functional electrical stimulation (FES) orthosis (E0770) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight additional PT visits in the home.
You asked the Plan to pre-approve the additional PT visits. You say that it is important that you receive PT under the supervision of a physical therapist due to multiple conditions. The Plan denied your request. The Plan says the medical documentation provided on your behalf did not indicate why any training or education needed has not already occurred with the prior physical therapy visits you have had. The Plan also says that the
documentation did not show why a skilled physical therapist is needed to oversee your home therapy program at this point.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional PT visits. Our reviewer says that the requested home health PT services are not shown to be medically necessary and reasonable. Our physician reviewer found you do not have documented skilled therapy needs. Our reviewer found that the limited documentation does not show whether progress has been/is being made and does not clearly show your current ambulation ability. Our physician reviewer also found that the documentation does show that you live in a facility with caregivers for assistance. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight additional PT visits in the home.