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

We decided that the Plan does not have to pay for the services (70450) provided on September 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 70450
is a column II code to column I code 70496. 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 (70450) provided on September 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
August 7, 2021, through August 14, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to
pay anything. The Plan denied your request. The Plan says the cost share 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 a $280
copay each day one through six for inpatient hospital care.
You have been asked to pay a $280 copay each day one through six for the inpatient hospital care. This service
falls within the inpatient hospital 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
the inpatient hospital care provided on August 7, 2021, through August 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August
17, 2021, by a Medicare opt-out provider.
You asked the Plan to pay for the periodontal maintenance (D4910). You say that this provider has been
rendering your annual periodontal cleanings for multiple years. You also say that the Plan has fully reimbursed
this provider since you began using Medicare. The Plan denied your request. The Plan says you received this
service from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider
opted out of Medicare effective May 2, 2016, to May 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 periodontal maintenance (D4910) provided on August 17, 2021, by a
Medicare opt-out provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and smoking cessation services
(99406) provided from April 19, 2021, through August 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services were medically necessary and
based on a referral. The Plan denied your request. The Plan says prior authorization was not obtained for these
services rendered by an OON 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 the office visit (99213) and smoking cessation
services (99406) provided from April 19, 2021, through August 12, 2021, by an out-of-network (OON)
provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
October 1, 2020, through October 9, 2020, with code PGYE1.
You asked the Plan to pay for the SNF services. You say that it is felt that the active diagnoses are supported by
the record. You agree with a change to the HIPPS code but feel that payment should be made for HIPPS code
PGYE1. The Plan denied your request. The Plan says the documentation supports a HIPPS code of PDYF1.
The payment in excess of that for this code was correctly recouped.
The Plan follows Medicare rules. Medicare rules say that SNF services are paid based on a HIPPS code which
is calculated using a variety of factors. Reported active diagnoses are among the factors which can affect the
HIPPS code for the episode of care.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that the
documentation does not support the reporting of septicemia or stroke as active diagnoses for this Our physician
reviewer found the enrollee is a 90-year-old woman with a history of breast cancer, ovarian cancer, transient
ischemic attack (TIA), and subdural hematoma, who was admitted to the hospital on 9/11/2020 with severe
sepsis evidenced by lactic acidosis and encephalopathy. The enrollee was diagnosed with a urinary tract
infection. On 9/15/2020, it is documented that the septic shock had resolved. The enrollee was admitted to a
facility on 9/18/2020. The initial NP visit following hospitalization for septic shock is dated 9/21/2020. The
enrollee's antibiotic had been switched to Bactrim on 9/16/2020; the last day of antibiotics was 9/18/2020. On
9/23/2020 it is documented that the enrollee "is recovered well from her E. coli urinary tract infection and
sepsis."
The documentation does not support septicemia (septic shock) as an active diagnosis for the dates 10/1/2020
through 10/9/2020. It is documented that the enrollee had a history of TIA with no recurrent symptoms. The
documentation does not support stroke or TIA as an active diagnosis for the dates 10/1/2020 through
10/9/2020.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided from October 1, 2020, through October
9, 2020, with code PGYE1.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ankle foot orthosis (L1940) molded plastic soft interface addition to lower extremity orthosis (L2820) lacer addition to lower extremity molded to patient model (L2330) provided July 6, 2021.

You asked the Plan to waive the copayment for the orthoses. You say that you are a senior person living on a very modest income. You should not have to pay for a medical device that does not match the description in the FAS-MA invoice. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance at a durable medical equipment provider.

You have been asked to pay $262.52 ($1332.60 x 20%) for the orthoses. The orthoses fall within the Durable medical equipment (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 copayment for ankle foot orthosis (L1940) molded plastic soft interface addition to lower extremity orthosis (L2820) lacer addition to lower extremity molded to patient model (L2330) provided July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on October 1, 
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 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 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 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 computed tomography (CT) scan rendered on 
October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (9336) provided on
February 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that it was medically necessary for
the enrollee to receive treatment and you did not know that the facility failed to get pre-authorization for this
enrollee, so you treated them anyways. 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. Non-
emergent services with non-contracted providers require prior authorization before services being rendered.
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 the domiciliary or rest home visit (9336) provided
on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services (11406) provided August 6, 2021.

You asked the Plan to pay for assistant at surgery services. You say that the services were provided in good faith. The Plan denied your request. The Plan says these services are not covered by Medicare.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered.

In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 11406. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for assistant at surgery services have not been met.

Therefore, we decided that the Plan does not have to pay for assistant at surgery services (11406) provided August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided May 20, 2021

You asked the Plan to pay for the office visit. You say that the Plan denied the claim the procedure code is incorrect. Medicare will not pay that procedure code and the Plan will not give out the code. The provider states that the only code they use is 99202 and they won't use any other. The Plan denied your request. The Plan says this service is not covered when rendered by a Chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) provided May 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth visit provided on November 1,
2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that the phone call only lasted a
couple minutes and no diagnosis was given. The Plan denied your request. The Plan says the proper copayment
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 $5
copayment for Primary care physician telehealth services.
You have been asked to pay a $5 copayment for a telehealth visit. A telehealth visit falls within the
Physician/Practitioner services, including doctor's office visits 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 telehealth visit provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 15, 2021 by
an out-of-network (OON) provider.
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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 the laboratory services provided on September 15, 2021 by an out-of-network (OON)
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on August 11, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed
adjacent to the CPT code for GeneSight testing.
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX
Z-Code. Based on this information, we decided that Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on
August 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for established patient, outpatient office visit (99212) individual
psychotherapy (90833) provided on March 30, 2021 to September 3, 2021 by an out-of-network (OON)
provider.

You asked the Plan to pay for the psychotherapy office visit. You say that you have been receiving treatment
with this provider for 2 years and this doctor has kept you stable. 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. Non-emergent services with non-contracted providers require prior authorization before
services being rendered.

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 established patient, outpatient office visit (99212)
individual psychotherapy (90833) provided on March 30, 2021 to September 3, 2021 by an out-of-network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 11, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were informed that all cost-sharing was waived for coronavirus related claims. 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 each urgent care visit. The file shows that coronavirus waivers were no longer in effect as of September 1, 2021. Therefore, you have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on September 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiac catheterization (93458) and
related services provided on September 1 to September 7, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for a cardiac catheterization. You say that you were misinformed
and misrepresented on the procedure at issue. The Plan denied your request. The Plan says the correct
copayment 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 $325
copayment for outpatient surgery services provided at an outpatient hospital.
You have been asked to pay a $325 copayment for a cardiac catheterization. A cardiac catheterization 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 cardiac
catheterization (93458) and related services provided on September 1 to September 7, 2021, at an outpatient
hospital facility.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities
from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on June 8, 2021.
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered.
The Plan denied your request. The Plan says the deductible 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. Your
contract with the Plan says that there is a $1000 deductible which applies to Physician/Practitioner services,
including doctor's office visits.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by
clearly disclosing in the contract that there is a $1000 deductible which applies to Physician/Practitioner
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at
the time the office visit was received on June 8, 2021. Therefore, we decided that the Plan does not have to
waive the deductible for an office visit provided on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471) provided on August 11, 2021.  You asked the Plan to pay for a shingles vaccine and administration. You say that you were told this would be covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your prescription drug plan.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90750) and administration (90471) provided on August 11, 2021.   Benefits for a shingles vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.