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

 We decided that the Plan does not have to pay for an ultrasound (76705) provided on August 19, 2021.  

You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this 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. In this case, we have confirmed that code 76705 is a column II code to column I code 93976. 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 ultrasound (76705) provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided on October 18, 2020.  You asked the Plan to pay for the unlisted molecular pathology procedure. You say that you would like the Plan to reconsider this claim. The Plan denied your request. The Plan says these services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting which is not what the billed POS indicates. 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 unlisted molecular pathology procedure (81479) provided on October 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an X-ray of the elbow provided on September 20, 2021.  You asked the Plan to waive the copayment for the X-ray. You say that the service should be covered completely. 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 $50 copayment for each X-ray performed in a provider's office.   You have been asked to pay $25.12, which is less than the $50 copayment for the X-ray. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray of the elbow provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on March 12, 2021.  You asked the Plan to pay for anesthesia services. You say that you would like this claim reprocessed based on medical documentation. The Plan denied your request. The Plan says no separate payment is made for this 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, 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, CPT code 99100 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 49654) provided to the enrollee on January 13, 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 requested service code is not substantiated by the clinical documentation in the operative report submitted for review  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 49654 is a column II code to column I code 49650. This claim has not been billed with an appropriate modifier to bypass the edit. 49654 is inclusive to a more comprehensive procedure in this case. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 49654) provided to the enrollee on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a chiropractic office visit provided to the enrollee on August 25, 2021.  You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.  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 a chiropractic office visit provided to the enrollee on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the imaging services coded as 93308, 93321, and 93325 provided on April 29, 2021.  You asked the Plan to pay for the imaging services. You say that you would like these services reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services were not billed with appropriate modifiers to bypass the PTP code edit.  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 codes 93308, 93321, and 93325 are column II codes to column I code 93306. These claims have 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 imaging services coded as 93308, 93321, and 93325 provided on April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from July 5, 2021, through July 6, 2021.  You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and insulin. The enrollee had stable vital signs. He was treated for pain with effect and a left ear infection. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT). By the dates in question, the enrollee was independent with functional mobility including gait to 200 feet with a wheeled walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from July 5, 2021, through July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Neuromuscular Electrical Stimulation (NMES) (E0745), provided on March 9, 2021.  You asked the Plan to pay for the NMES. You say that the service is medically necessary. The Plan denied your request. The Plan says the records show that this member does not have disuse muscle atrophy or spinal cord injury. The Plan follows Medicare 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 NMES. Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical records provided do not document any disuse atrophy on the physical examination of the enrollee which would be needed to approve the requested NMES. There also is no documentation of a spinal cord injury to meet Medicare criteria for coverage of an NMES.  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 NMES have not been met. Therefore, we decided that the Plan does not have to pay for the Neuromuscular Electrical Stimulation (NMES) (E0745), provided on March 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on July 15, 2021.  

You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 ambulance service, advanced life support, emergency transport, level 1. Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided there is no documentation that the enrollee's presenting symptoms met prudent layperson criteria for emergency care. The records document that the enrollee was stable after treatment in the hospital and the ambulance was called because she had "no ride home". The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport on July 15, 2021 was medically reasonable and necessary for the enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, advanced life support, emergency transport, level 1 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on July 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the outpatient psychological services provided on July 8, 2021.  You asked the Plan to pay for the psychological services. You say that this was medically necessary care. The Plan denied your request. The Plan says that there was no documentation of a consultation with the primary care physician, and no referring provider was listed on the claim.  The Plan must follow Medicare rules. Medicare rules say that while CPs are generally required to document consultation with the primary/attending physician for enrollees under their care, an exception is made when the attending/primary physician refers the enrollee for psychological consultation.  In this case, the claim lists a referring provider, which contradicts the Plan's assertion. There was no information provided to prove that the reported referring physician is not accurate. As such, we find that the denial rationale provided by the Plan is not supported. Therefore, we decided that the Plan has to pay for the outpatient psychological services provided on July 8, 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 genetic testing for infectious agents provided on August 12, 2020.  

You asked the Plan to pay for the genetic testing. You say that this is medically necessary testing. The Plan denied your request. The Plan says this was billed with an inappropriate POS code.  

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.  

We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing for infectious agents provided on August 12, 2020.
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 this procedure should be covered. 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, including ultrasounds.   

You have been asked to pay $91.29, which is less than the $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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapy services (G0283, 97016, 97112, 97139) and compounded drugs (J3490, J3411, J3420, J3415) with administration (96372) provided on May 19, 2021.  You asked the Plan to pay for the medical services. You say that the medical documentation supports the services billed. The Plan denied your request. The Plan says these services as billed are not eligible for payment.   The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP who is not licensed to provide physical therapy in the State of Wisconsin. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of therapy services and compounded drugs with administration have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (G0283, 97016, 97112, 97139) and compounded drugs (J3490, J3411, J3420, J3415) with administration (96372) provided on May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the methylprednisolone acetate injection provided on June 10, 2021.  

You asked the Plan to waive the coinsurance for the methylprednisolone acetate injection. You say that it is ridiculous that insurance won't pay this small amount. The Plan denied your request. The Plan says the coinsurance applied correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs.    

You have been asked to pay $2.15, which is 20% of the allowed amount for the methylprednisolone acetate injection. The allowed amount is $10.74 (20% x $10.74 = $2.15). The methylprednisolone acetate 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 the methylprednisolone acetate injection provided on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for hereditary genetic predictive screening testing provided on May 8, 2021.  You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was ordered by telemedicine which is a prohibited action and this testing is considered non-covered screening.  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, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary genetic predictive screening testing provided on May 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on August 12, 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 are not separately payable.  

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  

We looked at the file and Medicare rules. Billed procedure codes 29876 and 29881 are bundled into payment for approved code 26010, which was paid under a separate claim by the Plan. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a canceled strabismus surgery (67314) on August 13, 2021.  You asked the Plan to waive the copayment for strabismus surgery. You say that the provider could not complete the operation and nothing 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 $80 copayment for each outpatient surgery and/or services.   You have been asked to pay a $80 copayment for strabismus surgery. Strabismus surgery 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. Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of care received. Therefore, we decided that the Plan does not have to waive the copayment for a canceled strabismus surgery (67314) on August 13, 2021.   Your complaint about the provider canceling the surgery based on erroneous information 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone density scan (77080) provided on September 1, 2021.  You asked the Plan to pay for the bone density scan. You say that this was medically necessary. The Plan denied your request. The Plan says this service exceeded the benefit limit.  The Plan must follow Medicare rules. The rules say that Medicare pays for a screening bone mass measurement (BMM) once every 2 years.  We looked at the file and Medicare rules. The file shows that you previously had a bone density scan on August 31, 2020. The services on September 1, 2020, were performed less than two years from your previously covered scan. Based on this information, we decided that Medicare rules for coverage of the bone density scan have not been met. Therefore, we decided that the Plan does not have to pay for the bone density scan (77080) provided on September 1, 2021.