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

 We decided that the Plan does not have to pay for the laboratory services coded 81317, 81404, 81405, 81406, 81162, 81435, 81403, 81308, 81407, 81408, 81479, and 81437 provided on April 16, 2021.  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 are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes 81317, 81404, 81405, 81406, 81162, 81435, 81403, 81308, 81407, 81408, 81479, and 81437 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Therefore, codes 81317, 81404, 81405, 81406, 81162, 81435, 81403, and 81308 cannot be verified.  If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel. One code was not submitted for the services rendered. This means 81407, 81408, 81479, and 81437 are not separately payable.  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 coded 81317, 81404, 81405, 81406, 81162, 81435, 81403, 81308, 81407, 81408, 81479, and 81437 provided on April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on June 29, 2021, through July 31, 2021.  You asked the Plan to waive the copayment for SNF care. You say that the service should be covered. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $184 copayment each day 21-100; the first 20 days are covered for skilled nursing facility (SNF) care.   The enrollee has been asked to pay a $184 copayment each day 21-100; the first 20 days are covered for SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. The documentation provided indicates the enrollee was in a SNF for 33 days. The first 20 days were covered and the enrollee is responsible for the $184 copayment for each of the remaining 13 days. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on June 29, 2021, through July 31, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent observation care, per day, for the evaluation and management of a patient (CPT code 99225 X2) provided on December 5, 2020, and December 19, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that the code was denied as being paid for a different provider.

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. The Plan did not substantiate why this was denied and they did not provide evidence the services were already paid. Therefore, we decided that the Plan has to pay for subsequent observation care, per day, for the evaluation and management of a patient (CPT code 99225 X2) provided on December 5, 2020, and December 19, 2020.

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 pay for the coronavirus polymerase chain reaction (PCR) test (0202U) provided on April 16, 2021.  You asked the Plan to pay for the PCR test. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the PCR test is not covered.  The Plan must follow Medicare rules. Medicare rules say that revenue code 0202U - infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected - is specifically listed as a non-covered code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PCR test have not been met. Therefore, we decided that the Plan does not have to pay for the coronavirus polymerase chain reaction (PCR) test (0202U) provided on April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on December 17, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. You say that you were led to believe the lab would honor your plan for another year. The Plan denied your request. The Plan says the claim for services processed correctly.  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 lab 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 lab services provided on December 17, 2020, 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 the podiatry visit provided on August 3, 2021.

You asked the Plan to waive the copayment for the podiatry visit. You say that you are supposed to have a $0 copayment for foot care with a diabetic diagnosis. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each in and out-of-network Medicare-covered visit (medically necessary foot care).

You have been asked to pay a $15 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The medical record shows you had a follow-up visit for an ingrown toenail and a non-pressure chronic ulcer diagnosis which makes this a medical visit.

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 podiatry visit provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on May 11, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We looked at the file and the rules. We find that CPT codes 64450 and 64493 may be eligible for payment when billed along with CPT code 01935. The claim information does not show that the codes at issue were billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on May 11, 2021.
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 June 11, 2021.

You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be covered as you should not have to pay for a covid-19 test. 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 $30 copayment for urgently needed services.

You have been asked to pay a $21.08 copayment for an urgent care visit, which is less than the $30 stated in the Plan's contract. Per the Plans guidelines the cost-sharing waiver for covid-19 tests ended on April 1st, 2021, and since this was a pre-procedural test, it wouldn't have qualified to be waived. Urgent care visits fall 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 June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal orthotic device (D7880) provided on March 4, 2020.
You asked the Plan to pay for the occlusal orthotic device. You say that you would like reconsideration because this service was medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says CPT code D7880 is not valid for Medicare purposes.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Additionally, per the Physician Fee Schedule, CPT code D7880 has a status indicator of I. This means that CPT code D7880 is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the occlusal orthotic device (D7880) provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on June 2, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B". This means that payment for these services are always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI of the pelvis (72197) provided on October 6, 2021.  You asked the Plan to waive the copayment for the MRI of the pelvis. You say that the services should be covered due to the covid-19 lockdown. 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 $250 copayment for Outpatient diagnostic tests and therapeutic services and supplies.    You have been asked to pay a $250 copayment for an MRI of the pelvis. There are no Plan guidelines that state cost-sharing for MRI's will be waived due to the covid-19 pandemic. MRI's 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 an MRI of the pelvis (72197) provided on October 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device provided on July 27, 2021.  You asked the Plan to pay for the services provided. You say that the enrollee was at risk for developing deep vein thrombosis. The Plan denied your request. The Plan says payment for this service would have been included under the facility claim.  The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices are only covered under certain medical indications.     We looked at the file, and Medicare rules. A pneumatic compression device for the purpose of prevention of venous thromboembolism is not a covered benefit. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for X-rays provided on July 19, 2021.

You asked the Plan to waive the deductible for X-rays. You say that you should only owe $35 and not the higher charge. 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. Your contract with the Plan says that there is a $500 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. 

You received X-rays on July 19, 2021. The record shows that you had only paid $39.85 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $91.94. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time X-rays were received on July 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for X-rays provided on July 19, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound, transvaginal (76830) provided August 16, 2021.  You asked the Plan to waive the copayment for the transvaginal ultrasound. You say that this test has been covered in the past and you don't understand why it isn't covered this year. The Plan denied your request. The Plan says the copayment 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 $100 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility.  You have been asked to pay a $90.03 copayment for transvaginal 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 less than or equal to 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 ultrasound, transvaginal (76830) provided August 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99348) provided on November 17, 2020.

You asked the Plan to pay for the home visit. You say that you would like this claim to be reprocessed appropriately with the appended modifier. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home visit (99348) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist office visit provided on July 26, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that you are appealing this claim. You sent in your bill for review. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for services obtained from a specialist.    You have been asked to pay a $45 copayment for the specialist office visit. The specialist office 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 the specialist office visit provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services provided on August 5, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is not a covered benefit.

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 $35 copay for each visit to a specialist, such as an ophthalmologist. 

The file shows that you received refraction services during a medical eye exam. Eye refraction is only covered during routine eye exams. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and topical application of fluoride varnish (D1206) or pay more for the periodontal maintenance (D4910), pontics (D6242), and retainer crowns (D6752) provided from January 6, 2020, to May 10, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray and topical application of fluoride varnish, and to pay more for the periodontal maintenance, pontics, and retainer crowns. You say that it was your understanding that you would pay a 20% copay. You also say that you would like to know if the insurance paid 80%. The Plan denied your request. The Plan says these claims processed correctly in accordance with your 2020 Evidence of Coverage and 2021 Evidence of Coverage hand booklets.

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 first intraoral periapical x-ray (D0220) and topical application of fluoride varnish (D1206) are not among those covered under this benefit. The 2020 Evidence of Coverage states that you are responsible for a 50% coinsurance for periodontic services, and the 2021 Evidence of Coverage says that you are responsible for a 40% coinsurance for prosthodontics, including bridges. The record also shows that you had a running balance from March of 2019 which caused you to be billed for $1,018.75. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and topical application of fluoride varnish (D1206) or pay more for the periodontal maintenance (D4910), pontics (D6242), and retainer crowns (D6752) provided from January 6, 2020, to May 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for face down positioning device (CPT code E1399) provided from May 20, 2021, through June 2, 2021.

You asked the Plan to pay for the device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

This item or service is not a covered benefit. The Plan states these devices are statutorily non-covered because they do not fall within a Medicare benefit category and these types of devices are considered "precautionary devices" and also can be used for purposes other than the treatment of an illness or injury. Therefore, we decided that the Plan does not have to pay for face down positioning device (CPT code E1399) provided from May 20, 2021, through June 2, 2021.