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

 We decided that the Plan does not have to pay for the laboratory services rendered on January 27, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported.  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 80157, 80159, 80162, 80173, 80177, and 80201 not supported in the medical record. Specifically, the records show that urine specimens were collected, not venipuncture. 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 laboratory services rendered on January 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound (76775) provided on September 9, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you were not charged for this service when you last had it in 2020, and you feel this copayment is incorrect. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Ultrasounds require a $100 copayment.  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 diagnostic radiology services, such as ultrasounds, nuclear cardiac imaging, PET, MRI, and CT scans.  You have been asked to pay a $100 copayment for the ultrasound. Diagnostic radiology services, such as ultrasounds, nuclear cardiac imaging, PET, MRI, and CT scans require a $100 copayment. 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 retroperitoneal ultrasound (76775) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist visits provided on May 18, 2021, and August 19, 2021.  You asked the Plan to waive the copayments for specialist visits. You say that the receptionist said your copayment is $0 and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for specialist visits.   You had specialist visits on May 18, 2021, and August 19, 2021. Therefore, you are responsible to pay a $15 copayment per each visit. The total amount you owe is: $15 (copayment) x 2 (specialist visits) = $30.  You have been asked to pay the total copayment amount of $30 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided on May 18, 2021, and August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 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 billed are not separately payable. 

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for individual psychotherapy (90834) integrated biopsychosocial assessment (90791) provided August 11, 2021 to August 25, 2021.  You asked the Plan to pay for the outpatient services. You say that this should be covered because the provider may not be a medical provider, but she has the credentials to do such psychotherapy. The Plan denied your request. The Plan says the provider is a Marriage and Family Therapist is is an ineligible provider.  The Plan must follow Medicare rules. Medicare rules say that this PPO Plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the Plan, you can receive your care from either a network provider or an out-of-network provider.  We looked at the file and Medicare rules. The rendering provider is a Marriage and Family Therapist and is not an eligible provider. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy (90834) integrated biopsychosocial assessment (90791) provided August 11, 2021 to August 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for anesthesia services provided to the enrollee on June 4, 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 that there is a more specific code for this anesthesia for screening colonoscopy.  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 00811 is "Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified."  We asked our coder 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 services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found the anesthesia record describes a pre-procedure for screening colonoscopy. The procedure provided was colonoscopy with biopsy. If a diagnostic procedure (biopsy) is performed, the procedure in no longer considered a screening and becomes a diagnostic colonoscopy. Therefore, CPT 00811 would be appropriate code to report.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on June 4, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the prophylaxis (D1110), oral exam (D0120), periapical x-ray (D0220), and localized deliver of antimicrobial agents (D4381 x 2) provided on January 24, 2019.  

You asked the Plan to reimburse you for the dental services. You say that you were told to send in your dental bills. You say that you were not advised there was a time limit. You say that The Plan denied your request. The Plan says the claim for date of service in this case was received outside of the 12 month timeframe.  

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  

The record shows that a claim for the dental services was not filed until September 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to reimburse you for the prophylaxis (D1110), oral exam (D0120), periapical x-ray (D0220), and localized deliver of antimicrobial agents (D4381 x 2) provided on January 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aid fitting and adjustment provided on May 21, 2021 and June 2, 2021.  You asked the Plan to pay for the hearing aid fitting and adjustment. You say that this was an office visit, and you are appealing the denial. The Plan denied your request. The Plan says the service exceeded your benefit maximum.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only covers one hearing aid fitting every 3 years.   We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid fitting and adjustment have not been met. Specifically, the Plan paid for the hearing aid fitting provided on April 11, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the hearing aid fitting and adjustment provided on May 21, 2021 and June 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast ultrasounds (76641 x 2) provided on July 27, 2021.
You asked the Plan to pay for the diagnostic testing. You say that the ultrasound was medically necessary. The
Plan denied your request. The Plan says documentation to support medical necessity of the services was not
provided.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the diagnostic testing have not been met. Specifically, the file shows that there were no medical
records provided to determine medical necessity, despite multiple requests. Therefore, we decided that the Plan
does not have to pay for the breast ultrasounds (76641 x 2) provided on July 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 23, 2021.  You asked the Plan to waive the copayment for an ultrasound. You say that you should only owe a $30 copayment for imaging services. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $155 copayment for ultrasounds.     You have been asked to pay the allowed amount of $133.77, which is less than the $155 copayment for an ultrasound. An 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 provided on August 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable X-ray equipment (R0070) provided on July 28, 2021.
You asked the Plan to pay for the X-ray transportation services. You say that you would like the Plan to reprocess this claim. The Plan denied your request. The Plan says the claim as billed is not payable according to Medicare rules.
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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen. We find that CPT code R0070 is not supported in the medical record. Specifically, the provider reported transportation of portable radiology equipment but did not report setup codes, which does not follow industry standard coding rules. Transportation services are not reimbursable without the reporting of setup services. Based on this information, we decided that Medicare rules for coverage of the X-ray transportation services have not been met.
Therefore, we decided that the Plan does not have to pay for the transportation of portable X-ray equipment (R0070) provided on July 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 00140 provided on April 6, 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 billed are not supported by the documentation.  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 00140 is anesthesia for procedures on eye; not otherwise specified.    We find that CPT code 00140 is not supported in the medical record. Specifically, this anesthesia code was not billed with an appropriate surgical code that appropriately crosswalks to the anesthesia services. 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 00140 provided on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.

You asked the Plan to pre-approve Benlysta. You say that the enrollee has a diagnosis of lupus with features of a positive antinuclear antibody, hypocomplementemia, positive lupus anticoagulant, pulmonary embolism in 2011, rash, proteinuria with glomerulonephritis, and arthralgias. You also say that you would like this denial to be reconsidered. The Plan denied your request. The Plan says this drug does not meet the Medicare criteria to be covered under the enrollee's Medicare Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Benlysta.

Benefits for Benlysta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional PT visits.  You asked the Plan to pre-approve additional PT visits. You say that additional PT visits are medically necessary. The Plan denied your request. The Plan says additional PT visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been authorized additional therapy to be competent in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
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 June 18, 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 June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 4, 2020.

You asked the Plan to waive the copayment for a specialist visit. You say that you do not remember receiving the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for specialist visits. 

The medical records show that you had a specialist visit on March 4, 2020. Therefore, you are responsible to pay the $30 copayment. 

You have been asked to pay a $30 copayment for a specialist visit. A specialist 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 specialist visit provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the annual wellness visit received on August 18, 2021.  

You asked the Plan to pay for the annual wellness visit. You say that you needed your doctor to refill your prescriptions. The Plan denied your request. The Plan says the services received exceed your benefit limit.  

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months.   

Review of the file shows that you received an annual wellness visit on August 18, 2021. You previously received an annual wellness visit on February 3, 2021. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit received on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90471) provided on July 2, 2021.  

You asked the Plan to pay for a Tdap vaccine. You say that this should be covered. The Plan denied your request. The Plan says this vaccine is not covered in the absence of injury or exposure.  

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine. The Plan follows the same rules.   

Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90471) provided on July 2, 2021.   

Benefits for a Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 87481, 87640, 87653, and 87798 provided on April 22, 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 billed are 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 codes 87481, 87640, 87653, and 87798 for the laboratory services are a column II code to column I code 87150. 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 laboratory services coded 87481, 87640, 87653, and 87798 provided on April 22, 2021.