Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99204), the probing of a nasal tear duct (68840), and the diagnostic examination of the nasal passages (31231) rendered by the out-of-network (OON) provider on June 4, 2021.

You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The 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 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 issue reimbursement for the office visit (99204), the probing of a nasal tear duct (68840), and the diagnostic examination of the nasal passages (31231) rendered by the out-of-network (OON) provider on June 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the abdomen provided on August 25, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you had this same test three years ago and had a lower copayment. 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 $160 copayment for radiological diagnostic services, not including X-rays. 

You have been asked to pay $76.69, which is less than the $160 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 abdomen provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on May 11, 2021.
You asked the Plan to pay for the dental x-ray. You say that the panoramic x-ray was necessary due to receding
gums on your teeth. The Plan denied your request. The Plan says panoramic x-ray is not listed as a covered
service.
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 panoramic x-ray is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for panoramic x-ray
(D0330) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility discharge day management services coded 99316 provided on July 8, 2021.

You asked the Plan to pay for the nursing facility discharge day management 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 code 99316 is a column II code to column I code 90792. 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 nursing facility discharge day management services coded 99316 provided on July 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 4, 2021, to June 2, 2021.
You asked the Plan to pay for the home health services. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the non-contracted provider submitted the RAP claim on June 18, 2021 for the home health care period. The Plan also says that the deadline for submission of the final claim was within 5 days after the from date of May 4, 2021.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, May 4, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 4, 2021, to June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computerized tomography (CT) scan of the chest and abdomen/pelvis.

You asked the Plan to pre-approve CT scans. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scans. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of Stage IV colorectal carcinoma with metastatic disease to the lymph nodes, left/right ovary, and peritoneum. The enrollee stopped receiving palliative treatment on September 13, 2021 and had a CT of the chest, abdomen and pelvis. CT of the chest, abdomen and pelvis supported when medically necessary once every six (6) months for two (2) years, and then annually for three (3) years. CT surveillance is not medically necessary more frequently than every six months. There is no high-quality evidence that more frequent CT will be beneficial. Therefore, the enrollee does not meet criteria for the requested CT scans.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve computerized tomography (CT) scan of the chest and abdomen/pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 17, 2021.
You asked the Plan to pay for the eye refraction. You say that you did not ask for a refraction and you did not
know you would be charged for this service. The Plan denied your request. The Plan says eye refractions are
not covered by Original Medicare.
Medicare generally does not cover routine vision and eyewear services, such as eye refractions. However, the
Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage.
We looked at the file and the Plan's rules. Based on the information provided for review, the eye refraction was
performed as part of a diagnostic medical eye exam rather than routine services. Medical services are covered
by Original Medicare; however, Medicare does not cover routine eye exams or eye refractions. Based on this
information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore,
we decided that the Plan does not have to pay for the eye refraction (92015) provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for perfusionist services (86891, 99190, 99191, P9022) provided
on June 25, 2021.
You asked the Plan to pay for perfusionist services. You say that these were emergency services. The Plan
denied your request. The Plan says these services must be billed through the hospital.
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services furnished to
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.
We looked at the file and Medicare rules. The services at issue were provided while the enrollee was an
inpatient and must be billed through the hospital. Based on this information, we decided that Medicare rules for
coverage of perfusionist services have not been met. Therefore, we decided that the Plan does not have to pay
for perfusionist services (86891, 99190, 99191, P9022) provided on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 4, 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 August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from July
13, 2021, to July 20, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were never informed
of the cost and are not responsible for 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 20%
coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on July 13, 2021. The total allowed amount is $8,751.39 and 20% of that
is $1,750.28.
You received a Medicare Part B drug on July 20, 2021. The total allowed amount is $8,751.39 and 20% of that
is $1,750.28.
The total amount you owe is: $3,500.56.
You have been asked to pay the total coinsurance amount of $3,500.56 for Medicare Part B drugs. Medicare
Part B drugs fall 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 Medicare Part B drugs provided from July 13, 2021, to July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the contact lenses (V2599), modifications (V2531) and fitting services (92313) provided on June 2, 2021, to June 3, 2021.  

You asked the Plan to pay for the vision services. You say that these services are necessary for you to see properly, and you feel they should be covered under your medical benefit. The Plan denied your request. The Plan says services such as prescription eyeglasses or contact lenses that are provided to correct your vision are considered routine services and are not covered by Original Medicare. The Plan offers a supplemental benefit which covers up to $250 per year for eyewear. The Plan has paid this amount and you are responsible for the remaining cost of these services.  

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $250 per year for routine eyewear. You are responsible for any amount above the eyewear coverage limit.  

We looked at the file and the Plan's rules. The record indicates that these services were requested for the purpose of improving your vision. These services are considered routine. Documentation shows that the Plan has paid $250 for these services, and you are responsible for the remaining amount. Based on this information, we decided that the Plan has paid the correct amount for these services based on your contract. Therefore, we decided that the Plan does not have to pay any additional amount for the contact lenses (V2599), modifications (V2531) and fitting services (92313) provided on June 2, 2021, to June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for revascularization services provided on July 12, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code cannot be verified.  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 37228 is revascularization, endovascular, open, or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty.     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 provided. Our reviewer found that the operative report documents an atherectomy and angioplasty of right tibial-peroneal trunk. All interventions performed in a territory for the same leg together are combined and the most complex intervention is reported. In this case, the procedures were reported incorrectly.  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 provided have not been met. Therefore, we decided that the Plan does not have to pay for revascularization services provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on May 24, 2021, by an outof-
network (OON) provider.
You asked the Plan to pay for the surgical services provided by an OON provider. You say that you would like
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network
care.
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 surgical services provided on May 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal injections at three levels bilaterally.

You asked the Plan to pre-approve spinal injections at three levels bilaterally. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a 
covered benefit.

The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, 
are allowed per session per spine region.

We looked at the file and Medicare rules. Review of the file shows that three levels bilaterally are being 
requested for injection services. Based on this information, we decided that Medicare rules for coverage of 
spinal injections at three levels bilaterally have not been met. Therefore, we decided that the Plan does not have 
to pre-approve spinal injections at three levels bilaterally.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on
February 10, 2021, to February 19, 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 DRG was updated in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 314 (OTHER CIRCULATORY SYSTEM
DIAGNOSES WITH MCC). 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 services. Our
reviewer says that the services at issue in this case were not supported by the medical records. Our physician
reviewer found the review has determined that the correct DRG and diagnosis codes were not used in this case.
The revised DRG 292 was more appropriate. The documentation supported the diagnosis of acute on chronic
heart failure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee on February 10, 2021, to February 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July 2,
2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that review of the literature and provided documentation do not support the rationale for performance of
this test in this clinical setting. Guidelines do not support a need for this test panel. As a result, at this time the requested testing would not be considered medically reasonable and necessary in this enrollee's clinical management. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the heart provided on
April 21, 2021.
You asked the Plan to waive the copayment for an ultrasound of the heart. You say that you disagree with the
charges because you should only owe a $20 copayment. 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 $90
copayment for ultrasounds.
You have been asked to pay a $90 copayment for an ultrasound of the heart. An ultrasound of the heart 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 heart provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a darbepoetin alfa injection provided on
June 2, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that The amount charged is different
than other claims. The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for Part B drugs and other outpatient services, including erythropoiesis stimulating agents.
You have been asked to pay $66.12, which is 20% of the allowed amount for the injection ($330.60 allowed
amount x 20% coinsurance = $66.12).
The 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 a darbepoetin alfa injection provided on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on March 29, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  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.  Review of the file shows that the documentation does not support that this service is likely to impact therapeutic decision-making in the clinical management of the enrollee. This means that the targeted genomic sequence analysis panel testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on March 29, 2021.