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

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 2, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. 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. Providers must report services with the appropriate CPT code. This code represents part of an expanded pharmacogenomic panel. The rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the component test results when medically reasonable and necessary. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the beneficiary and using the results in the management of the beneficiary's specific medical problem. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on August 2, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the laboratory services and the hospital outpatient clinic visit provided
on June 28, 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 that the services were rendered without prior
authorization.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has indicated that there was a claim submission error.
However, there has been no explanation provided of what the claim error was nor has the Plan substantiated
their denial. Therefore, we decided that the Plan has to pay for the laboratory services and the hospital
outpatient clinic visit provided on June 28, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 26, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4550, 77003) provided on June 19, 2021, and
August 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not
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 77003
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim
submitted, Medicare billing criteria have not been met.
Medicare rules also say that a status indicator of "B" under the Physician Fee Schedule indicates that payment
for covered services are always bundled into payment for other services not specified. Code A4550 is assigned
a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service.
Payment for this service is bundled into payment for other services. No separate payment can be made for this
service. Therefore, we decided that the Plan does not have to pay for the services (A4550, 77003) provided on
June 19, 2021, and August 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services
coded 99601 provided on August 10, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration 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 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, the CPT Code Manual definition of code 99601 is home infusion/specialty drug administration, per
visit (up to 2 hours).
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status code of
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided
that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601
provided on August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (63709) provided on July 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 63709 is a column II code to column I code 63267. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (63709) provided on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit and injection rendered on October 5, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you should not be paying this amount. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of
the cost for Medicare Part B prescription drugs for members and a $40 copayment for each office visit or telehealth visit to providers other than your physician of choice (POC) or primary care physician.
Review of the file shows that you received an injection of aminolevulinic acid HCl on October 5, 2021. You have been asked to pay 20% of the cost for these services, for a total of $78.50. These services fall within the Medicare Part B prescription drugs for members 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.
The file shows that you had an office visit on October 5, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the office visit or telehealth visit to providers other than your POC or primary care physician 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 the office visit and injection rendered on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the psychotherapy service (90832) rendered by the out-of-network (OON) provider on September 21, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 issue reimbursement 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to issue reimbursement for this service. Therefore, we decided that the Plan does not have to issue reimbursement for the psychotherapy service (90832) rendered by the out-of-network (OON) provider on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection of a major joint or bursa (20610) and the betamethasone acetate injection (J0702) provided on
August 25, 2020.
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 services 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 $175 copayment for each Medicare-covered visit at a hospital affiliated outpatient hospital facility or ambulatory surgical center.
You have been asked to pay a $175 copayment for the Medicare-covered visit at an outpatient hospital facility. 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 arthrocentesis, aspiration and/or injection of a major joint or bursa (20610) and the betamethasone acetate injection (J0702) provided on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization administration (CPT code 90471) and Tetanus CCPT code 90714) provided on September 29, 2021.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you deny any open wound or injury necessitating the Tetanus immunization.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for immunization administration (CPT code 90471) and Tetanus CCPT code 90714) provided on September 29, 2021.
Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power seat elevation feature (E2300) to be used with an approved power wheelchair.
You asked the Plan to pay for the requested power seat elevation feature. You say that this is necessary for you to function in your home. The Plan denied your request. The Plan says the chair and other accessories were approved. However, the E2300 power seat elevator is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that power seat elevators (E2300) are noncovered since they are not primarily medical in nature. Although the use of this feature may be appropriate, it does not meet the definition of Durable Medical Equipment and cannot be covered by Medicare. Therefore, we decided that the Plan does not have to pay for a power seat elevation feature (E2300) to be used with an approved power wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system (33264), provided on May 3, 2021.
You asked the Plan to waive the copayment the removal of a pacing cardioverter-defibrillator pulse generator. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 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 20% coinsurance for Outpatient hospital services.
You have been asked to pay a 20% coinsurance for the removal of a pacing cardioverter-defibrillator pulse generator (the allowed is $31,376 x 20% = $6,275.38), however, since your maximum out-of-pocket was met, you are instead being assessed a $4,723.29 copayment. Removals of pacing cardioverter-defibrillators fall within the Outpatient hospital 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 copayment for the removal of a pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system (33264), provided on May 3, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses provided on June 25, 2021.
You asked the Plan to pay for polycarbonate lenses. The Plan denied your request. The Plan says polycarbonate lenses are not covered by the Plan.
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 additional lens options including polycarbonate
are not covered. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses provided on
June 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion administration service (99601) provided on August 5, 2021.
You asked the Plan to pay for home infusion 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 this code is not valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that code 99601 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. This code is not payable for Medicare purposes and is not payable. Based on this information, we decided that Medicare rules for coverage of home infusion service have not been met. Therefore, we decided that the Plan does not have to pay for home infusion administration service (99601) provided on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive metabolic panel (80053) and an x-ray of the chest (71046) provided on September 7, 2021.
You asked the Plan to waive the copayment the comprehensive metabolic panel and an x-ray of the chest. You say that the services should be covered as a wellness visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $120 copayment and a $10 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $120 copayment for an x-ray of the chest and a $10 copayment for the comprehensive metabolic panel. Comprehensive metabolic panel and x-rays fall 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 a comprehensive metabolic panel (80053) and an x-ray of the chest (71046) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided to the enrollee by an out-of-network provider on July 27, 2021.
You asked the Plan to pay for the telehealth services. The Plan denied your request. The Plan says this is not a covered service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that out-of-network telehealth services are not covered. Review of the file shows that the enrollee was provided out-of-network telehealth services on July 27, 2021.
The Plan does not cover out-of-network telehealth services. Therefore, we decided that the Plan does not have to pay for the telehealth services provided to the enrollee by an out-of-network provider on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the PCD (CPT code E0675) and segmental gradient pressure
pneumatic appliance (CPT code E0673) provided to the enrollee on July 29, 2021.
You asked the Plan to pay for the DME. You say that the services are not considered experimental or
investigational. The Plan denied your request. The Plan says the services cannot be billed separately.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. The LCD 33829 state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Payment for this service would have been included under the facility claim. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the PCD (CPT code E0675) and segmental gradient pressure pneumatic appliance (CPT code E0673) provided to the enrollee on July 29, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services received on
October 10, 2021.
You asked the Plan to waive the copayment for the services. You say that they did not let you go into the office
due to a severe cough. The Plan denied your request. The Plan says the copayment was applied appropriately.
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 $110
copayment for emergency room care.
You have been asked to pay a $110 copayment for the services. The services fall within the emergency room
care 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 emergency room services
received on October 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on January 5,
2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the drug testing services (G0483) provided on January 5,
2021.