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

 We decided that the Plan does not have to waive the copayment for an MRI scan of the breast (77049) provided on September 26, 2019.  

You asked the Plan to waive the copayment for an MRI scan of the breast. You say that the service at issue should be considered preventative care. 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 $50 copayment for diagnostic radiology.   

You have been asked to pay a $50 copayment for an MRI scan of the breast. An MRI scan of the breast is not classified as preventative care. An MRI scan of the breast 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 MRI scan of the breast (77049) provided on September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for wound debridement services (11042) provided on July 1, 2021.  You asked the Plan to waive the copayment for wound debridement. You say that your wound was washed and wrapped in a bandage and that no surgical procedure was done. 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 $400 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.   You have been asked to pay a $400 copayment for wound debridement. Wound debridement falls within the "Outpatient Surgery and Other Medical 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 wound debridement services (11042) provided on July 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 22, 2021.    

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when the services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  

The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on March 22, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on June 28, 2021.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that the enrollee received no service from this company on this date of service. You also say that you believe this is a billing mistake because the enrollee was not moved from the skilled nursing facility. The Plan denied your request. The Plan says that this service is not covered under the enrollee's plan.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ground mileage and non-emergency ambulance transportation. Our reviewer says that these services were medically reasonable and necessary for the enrollee. Our physician reviewer found based on the ambulance records and the signed Physician's Certification Statement (signed by a valid non-physician) there is documentation that the enrollee was confused and combative and required monitoring during transport such that the expertise and services that only a fully-equipped ambulance could provide was necessary for safe transport on June 28, 2021. Our reviewer found that the enrollee was not bed confined but her mental status condition did meet criteria for ambulance transport. Our physician reviewer also found that even though the enrollee ultimately was not seen by the doctor at the office visit due to the appointment being cancelled by the family, the ambulance crew were not aware of this fact and transported the enrollee in good faith with the understanding that the medical visit was necessary.  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 ground mileage and non-emergency ambulance transportation have been met. Therefore, we decided that the Plan has to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder testing rendered on July 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 covered.  The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.  We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laser treatment for inflammatory skin disease (psoriasis) (96920) provided on August 11, 2021.  You asked the Plan to pay for the laser treatment (96920). You say that the code is billable with the patient diagnosis and the claim should be paid. The Plan denied your request. The Plan says CPT code 96920 is only reportable for psoriasis per the code description and a diagnosis to support the code was not reported on this claim.  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 96920 is laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm.  We find that CPT code 96920 is not supported in the medical record. Specifically, CPT code 96920 cannot be paid with the diagnosis code billed on the claim. Based on this information, we decided that Medicare rules for coverage of the laser treatment (96920) have not been met. Therefore, we decided that the Plan does not have to pay for the laser treatment for inflammatory skin disease (psoriasis) (96920) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for ophthalmological services (J0178, 67028, 92012, 92134) rendered on April 26, 2021.  

You asked the Plan to pay for ophthalmological services. You say that you were in Florida and was unable to return home due to the coronavirus (Covid-19). You also say that you were bleeding in your left eye and had to go see this provider while you were in Florida. The Plan denied your request. The Plan says that for out-of-network services, your primary care provider (PCP) is responsible for obtaining an authorization or providing you with a referral depending on the services being rendered. Your PCP or other contracted provider is responsible for obtaining this 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. We find that the Plan failed to make any attempts to obtain medical records. Therefore, we decided that the Plan has to pay for ophthalmological services (J0178, 67028, 92012, 92134) rendered on April 26, 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 laboratory services provided on July 22, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  

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 laboratory services provided on July 22, 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 the prolonged evaluation and management services provided on February 17, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the documentation does not support additional services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code G2212 is prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). The file shows that CPT code 99205 and 1 unit of CPT code G2212 was billed and paid for by the Plan. We find that an additional unit of CPT code G2212 is not supported in the medical record. The records show that 75 minutes of service was provided. This is indicative of the services paid by the Plan. The medical records do not show that additional services were provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management services provided on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional 3 units of wound debridement (11042) provided on July 1, 2021.  You asked the Plan to pay for the additional 3 units of wound debridement (11042). You say that notes are attached for reconsideration of the claim. The Plan denied your request. The Plan says CPT code 11042 has an MUE value of 1 but 4 units were billed. The Plan says that per guidelines, the Medicare rule for payment has not been met.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 11042 is 1. The MAI value for this code is 2. You billed 4 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the additional 3 units of wound debridement (11042) have not been met. Therefore, we decided that the Plan does not have to pay for the additional 3 units of wound debridement (11042) provided on July 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiofrequency ablation (64625) on May 24, 2021.  You asked the Plan to pay for the radiofrequency ablation (64625). You say that medical necessity is met per the standard guidelines. You say that supporting medical records are attached and the claim should be reprocessed. The Plan denied your request. The Plan says radiofrequency ablation for sacroiliac joint pain is considered not medically necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency.  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 pay for the radiofrequency ablation (64625). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment.  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 radiofrequency ablation (64625) have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (64625) on May 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on August 3, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an arthrocentesis, aspiration, and/or injection procedure (20610) provided on September 2, 2021.  You asked the Plan to waive the copayment for an arthrocentesis, aspiration, and/or injection. You say that if you had known about the copayment you would have declined the service 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 $225 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.   You have been asked to pay a $225 copayment for an arthrocentesis, aspiration, and/or injection. An arthrocentesis, aspiration, and/or injection 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 an arthrocentesis, aspiration, and/or injection procedure (20610) provided on September 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 23, 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 76770 (abdominal ultrasound) and 93976 (vascular study). Code 76770 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76770 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 abdominal ultrasound rendered on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for testing services provided to the enrollee on June 14, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 93000 is a column II code to column I code 93280. 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 testing services provided to the enrollee on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a biopsy of tongue (41100) provided on March 9, 2021, by an out-of-network provider.  You asked the Plan to pay for a biopsy of tongue. You say that you chose the provider of the services at issue from the Plan website. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 biopsy of tongue (41100) provided on March 9, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on August 24, 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 domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on August 24, 2021.