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

We decided that the Plan does not have to pay for the outpatient office visit (99204) Electrocardiogram, with interpretation and report (93040) provided on September 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99204) Electrocardiogram, with interpretation and report (93040) provided on September 29, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wheelchair ramp provided on August 30, 2021, by an online retailer.
You asked the Plan to pay for a wheelchair ramp. You say that the requested item was a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for payment have not been met because the supplier of the item at issue is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a wheelchair ramp provided on
August 30, 2021, by an online retailer
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on
June 2, 2021 to June 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the SNF services. You say that you submitted for prior authorization and received the supporting documentation. Please reprocess this claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior authorization before services being rendered. Submission was received for outpatient therapy.
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 skilled nursing facility (SNF) services provided on June 2, 2021 to June 16, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a coronary artery catheter insertion procedure performed on July 7, 2021.  You asked the Plan to waive the copayment for the catheter insertion. You say that you feel that the provider is balance billing you. 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 $360 copayment for surgery or other services provided to you at an outpatient hospital.   You have been asked to pay a $360 copayment for the catheter insertion. The catheter insertion falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a coronary artery catheter insertion procedure performed on July 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear medicine study (78452) provided on June 1, 2021.
You asked the Plan to waive the copayment for the nuclear medicine study. You say that you do not understand these bills, as you have not had to pay out-of-pocket for this care before, and now have questions about bills from multiple dates of service. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. The Plan is addressing your other concerns in separate cases.
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 Medicare-covered radiological diagnostic services other than x-rays. You have been asked to pay a $160 copayment for the nuclear medicine study. A nuclear medicine study falls within the Medicare-covered radiological diagnostic services other than x-rays 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 nuclear medicine study (78452) provided on June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rotary wing air transport (A0431), and rotary wing air mileage (A0436) provided on June 12, 2021.  You asked the Plan to pay for the air transportation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the air transportation services were not medically necessary.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 air transportation services. Our reviewer says that the air transportation services are not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee was hemodynamically stable at the time of transport. The reviewer found that the documentation did not support that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The reviewer also found that the documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee. Therefore, the reviewer found that the air transportation services were not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air transportation services have not been met. Specifically, the file does not show that the enrollee's condition was such that the time needed to transport the enrollee by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport (A0431), and rotary wing air mileage (A0436) provided on June 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the second eye exam (92012) provided on August 18, 2021.
You asked the Plan to pay for the second eye exam. You say that you received two separate eye exams for two separate issues from two different providers on the date in question, and these services should be paid. The Plan denied your request. The Plan says that the eye exams were billed on the same date from the same facility using codes 92014 and 92012. Both providers are within the same group and have the same specialty. Per Medicare rules, there are no circumstances in which both procedures of this code pairing should be paid for the same beneficiary on the same day by the same provider. Please note that the Plan is also not holding you liable for the services billed with code 92012 on August 18, 2021. You are not responsible for this payment.
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 92014 is a column II code to column I code 92012. The means that CPT code 92012 is not eligible for separate reimbursement under Medicare coverage rules. Therefore, we decided that the Plan does not have to pay for the second eye exam (92012) provided on August 18, 2021.
Please note that while the Plan does not have to pay for these services, the Plan is also not holding you liable for this payment. If you believe you are being balance billed, you should contact the provider or your Medicare Regional Office for assistance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on August 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the rendering dentist is not an in-network provider.
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 dental services provided on August 31, 2021, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visits (99214-25) provided from May 26, 2021, to July 28, 2021.  You asked the Plan to pay for the office visits. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 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 the rules. The file shows that the enrollee received an office visit, in which osteopathic manipulative treatment was provided. The records do not show that a separately identifiable evaluation and management service was provided and is therefore not separately reportable. Therefore, we decided that the Plan does not have to pay for the office visits (99214-25) provided from May 26, 2021, to July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the manual manipulation of the spine (98941) and the electrical stimulation (G0283) provided on July 17, 2021.  You asked the Plan to pay for codes 98941 and G0283. You say that the provided manual manipulation of the spine (98941) and electrical stimulation (G0283) provided on July 17, 2021, was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the provided manual manipulation of the spine (98941) provided on July 17, 2021. Furthermore, code G0283 (electrical stimulation) is not covered when billed by a chiropractor.  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.   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 codes 98941 and G0283 Our reviewer says that the enrollee did not meet criteria for the provided manual manipulation of the spine (98941) provided on July 17, 2021. Our physician reviewer found the enrollee complained of neck and low back pain beginning on April 20, 2021. The orthopedic evaluation revealed pain to touch in the areas of complaint. The neurological evaluation was within normal limits. A cervical series, a thoracic series, and a lumbar series were performed. The results of the imaging are not available in the case file. The enrollee was diagnosed with radiculopathy in the lumbosacral region, segmental and somatic dysfunction of the lumbar and thoracic regions, and myalgia, other site. The documentation does not support that the enrollee has subluxation demonstrated by x-ray or physical exam.  We looked at this physician's review, the file, and Medicare rules. The records also show that the electrical stimulation (G0283) at issue is not manual manipulation of the spine and is not covered. Based on this information, we decided that Medicare rules for coverage of codes 98941 and G0283 have not been met. Therefore, we decided that the Plan does not have to pay for the manual manipulation of the spine (98941) and the electrical stimulation (G0283) provided on July 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673).  You asked the Plan to pay for a pneumatic compression device and appliance. You say that you believe you have been falsely charged for a service you did not receive. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 30, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit for vision care provided on October 28, 2021.  You asked the Plan to waive the copayment for an office visit for vision care. The Plan denied your request. The Plan says this claim was processed correctly according to the member's 2021 Evidence of Coverage.  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 Vision Care, Medicare Covered Vision Services, Specialist Office.   You have been asked to pay a $45 copayment for an office visit for vision care. The office visit for vision care falls within the Vision Care, Medicare Covered Vision Services, Specialist Office 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 office visit for vision care provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on July 12, 2021.  You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 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 review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on
July 23, 2021 to July 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the SNF care. You say that you were under the impression that an in network facility was being sought. You say that there were no beds available at in network facilities. You also say that you felt pressured by the hospital to be discharged quickly. The Plan denied your request. The Plan says services rendered at a network facility are not covered. The Plan also says that authorization was not obtained before you received the services.
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 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 skilled nursing facility (SNF) care provided on July 23, 2021 to July 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 22, 2021.
You asked the Plan to pay for the hearing aids. You say that you were not aware that you had to purchase hearing aids from an in-network provider. You say that you limit driving, and you live alone and felt it was safer to go somewhere close. The Plan denied your request. The Plan says hearing aids must be provided by an in-network provider to receive the benefit.
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 pays for hearing aids only when provided through the Plan's hearing aid provider. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Laser treatment for inflammatory skin disease (psoriasis) (96921) provided on July 12, 2021.  You asked the Plan to pay for code 96921. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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 96921 is Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm.  We find that CPT code 96921 is not supported in the medical record. Specifically, codes 96920-96922 should not be reported for treatment of any inflammatory disease other than psoriasis. In this case, the medical record does not indicate the laser services were performed to treat psoriasis. Based on this information, we decided that Medicare rules for coverage of code 96921 have not been met. Therefore, we decided that the Plan does not have to pay for the Laser treatment for inflammatory skin disease (psoriasis) (96921) provided on July 12, 2021.