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

We decided that the Plan does not have to pay for an x-ray (71045) provided on September 22, 2021.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this cannot be paid separately without a modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045
is a column II code to column I code 71046, which was billed on this date of service by the same provider on a
separate claim. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have
to pay for an x-ray (71045) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014) and the scanning computerized ophthalmic diagnostic imaging with interpretation and report (92133) rendered by the out-of-network (OON) provider on July 21, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014) and the scanning computerized ophthalmic diagnostic imaging with interpretation and report (92133) rendered by the out-of-network (OON) provider on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a denosumab injection provided on July 6, 2021.

You asked the Plan to waive the coinsurance for the injection. You say that you feel that the copayment is too high. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 Part B drugs, including injectable osteoporosis drugs. 

You have been asked to pay $251.64, which is 20% of the allowed amount for the injection ($1258.20 allowed amount x 20% coinsurance = $251.64). The injection falls within the Medicare Part B Prescription Drugs 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 a denosumab injection provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 9, 2020.

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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the trigger point injection (20552) rendered by the out-of-network (OON) provider on April 29, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and the trigger point injection (20552) rendered by the out-of-network (OON) provider on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 16, 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 services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on August 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on May 24, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that your provider depends upon to facility to verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 a practitioner visit provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor sensors (K0553) 
provided on March 15, 2021.

You asked the Plan to pay for Freestyle Libre sensors. You say that the items at issue were prescribed by the 
doctor to minimize the deterioration of the enrollee's function and condition. The Plan denied your request. The 
Plan says rules for payment have not been met.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 
sensors have not been met. Therefore, we decided that the Plan does not have to pay for Freestyle Libre 
continuous glucose monitor sensors (K0553) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014) rendered by the out-of-network (OON) provider on March 11, 2021.

You asked the Plan to pay for this service. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 pay for this service. Therefore, we decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92014) rendered by the out-of-network (OON) provider on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87481, 87491, 87591, 87640, 87496, 87511, 
87641, 87651, 87661, 87798, 87529, 87532) provided July 1, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.

We looked at the file and Medicare rules. Insufficient medical records were provided to determine if the tests 
were ordered by the treating physician, and if the tests were medically necessary. 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 lab services (87481, 87491, 87591, 87640, 87496, 87511, 87641, 87651, 87661, 
87798, 87529, 87532) provided July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on November 23, 2020.

You asked the Plan to pay for this service. 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 pay for this service. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for drug test. You say that you perform drug monitoring in good faith at the request of the ordering physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and this testing was not ordered by an in-network provider.
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 items/services at issue in this appeal. 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 drug testing provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services (97602) provided May 10, 2021.

You asked the Plan to pay for the wound care services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 97602 is not supported in the medical record. Specifically, this code has a status of "B" per the National Physician Fee Schedule Relative Value file. Payment is always bundled with another service. Based on this information, we decided that Medicare rules for coverage of the wound care services have not been met. Therefore, we decided that the Plan does not have to pay for wound care services (97602) provided May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nerve block provided on September 9, 
2021.

You asked the Plan to waive the copayment for a nerve block. You say that you did not know you would owe a 
high copayment for this procedure. You state that this was a test and it did not work. 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 a $195 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You have been asked to pay a $195 copayment for a nerve block. A nerve block falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 nerve block provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and panoramic x-ray provided on 
August 17, 2021.

You asked the Plan to pay for the limited oral evaluation and panoramic x-ray. You say that you chose to see 
your doctor because there were none in-network within 100 miles. You say that you don't have the money to 
pay up front and you are disputing the bill. The Plan denied your request. The Plan says the services are not 
covered benefits.

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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation and panoramic x-ray provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on August 14, 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 71045 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, 2 views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on August 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on June 16, 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 codes S1015 and S8301 are 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 codes S1015 (intravenous tubing extension set) and
S8301 (infection control supplies) have 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 supplies rendered on June 16, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a transport chair (E1038) provided on July 30, 2021.

You asked the Plan to pay for a transport chair. You say that the item at issue was a necessity for your care.
The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the 
items at issue is not enrolled in the Medicare program.

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 a transport chair (E1038) provided on 
July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic dental casts (D0470) provided on September 7, 2021.

You asked the Plan to pay for diagnostic casts. You say that the cost of this service should be included with your dentures, since they are necessary for this service. The Plan denied your request. The Plan says this service is not covered by your dental benefit.

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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the diagnostic dental casts (D0470) provided on September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on May 6, 2021, and May 25, 2021.

You asked the Plan to waive the copayments for ultrasounds. You say that you cannot afford the charges and request that the Plan pay them. 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 a $40 copayment for advanced imaging services. 

You received ultrasounds on May 6, 2021, and May 25, 2021. Therefore, you are responsible to pay a $40 copayment per each ultrasound. The total amount you owe is: $40 (copayment) x 2 (ultrasounds) = $80. 

You have been asked to pay the total copayment amount of $80 for ultrasounds. Ultrasounds 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 copayments for ultrasounds provided on May 6, 2021, and May 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck provided on July 15, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you feel that insurance should cover the larger portion of the bill. 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 $110 copayment for each radiological diagnostic service performed in a physician's office or free-standing facility, including ultrasounds.

You have been asked to pay a $110 copayment for the ultrasound. The ultrasound 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 an ultrasound of the head and neck provided on July 15, 2021.