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

We decided that the Plan does not have to pay for laboratory services (81401, 81403, 81404, 81405, 81406) provided on January 25, 2021.
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with a correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81401, 81403, 81404, 81405, 81406) provided on January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on March 28, 2021.
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the ambulance transport was medically necessary. 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, basic life support, emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our
physician reviewer found that the enrollee is a 50-year-old male who was transported via ambulance after
calling 911 for leg pain from a burn infection which he had been dealing with for weeks. He stated that he had
not been taking the prescribed medications for his leg infection following a recent emergency department
discharge. He required no treatment on transport. The enrollee's vitals were stable. He also had been drinking
alcohol and smoking cigars. The Coronavirus screening was positive. The enrollee did not present with signs
and symptoms to meet prudent layperson criteria for emergency care. Other means of transport were not
contraindicated such as stretcher van, wheelchair van, or taxi. The records did not support that the enrollee
required expertise or special equipment. Therefore, this request for ambulance services on March 28, 2021 will
be considered not medically necessary based on the provided documentation suggesting it was a non-emergent
transportation.
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, basic life support, emergency transport have not been met.
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency
transport (A0429, A0425) provided on March 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an orthopedic surgeon on July 12, 2012.
You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that this was a pre-operative visit and the cost should be included in the cost of the surgery. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for visits with a specialist.
Medicare rules state that when you have a surgery, the costs of certain services are included in the cost for the surgery itself. This is called a global surgical package. The only preoperative services included in the global surgical package are preoperative visits after the decision is made to operate, beginning with the day before surgery for major procedures. That was not the case here. The medical records show that the decision to proceed with surgery was made during this visit, not prior to this visit. Because of this, this preoperative visit does not count as part of the global surgical package, and therefore separate cost sharing applies. You have been asked to pay a $30 copayment for the orthopedic surgery visit. The orthopedic surgery visit falls within the visits with a specialist 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 office visit you had with an orthopedic surgeon on July 12, 2012.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computerized dynamic posturography (CDP).
You asked the Plan to pre-approve the CDP. You say that the requested CDP test is medically necessary. You
say that you have fallen and broken your arm multiple times this summer and they need to find out why you are
falling all of the time. The Plan denied your request. The Plan says the medical benefit of CDP has not been
established in peer reviewed literature. The Plan says that there is insufficient clinical evidence to determine
medical usefulness of CDP. The Plan says that this test is considered experimental and investigational.
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 pre-approve the CDP. Our reviewer says that a CDP
is not considered medically reasonable and necessary in this case. Our physician reviewer found the evidence
within published peer-reviewed medical literature on the safety and effectiveness of computerized dynamic
posturography (CDP) largely consists of older studies, some of which were poorly designed, with varying
results that were conflicting in nature. Most of these studies had marked methodological limitations including
but not limited to small sample sizes, non-randomization, inadequate follow-up and poor design which have
prohibited the generalizability of published study results.
In addition, of those studies that reported a positive outcome, there have not been any well-designed studies
conducted to validate the results of the preliminary studies. Furthermore, the data from published studies have
failed to demonstrate any beneficial effects of CDP evaluation on patient outcomes and management. Given all
of these limitations, particularly the need for further study of the technology to determine if it has any benefit
on outcomes and utility in practice, CDP is considered experimental/investigational.
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 CDP have not been met. Therefore, we decided that the Plan does not have
to pre-approve computerized dynamic posturography (CDP).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lumbar spine you had on June 27, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you should not have to pay this copayment because you had a failed surgery. The Plan denied your request. The Plan says this copayment was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for diagnostic radiological services. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the diagnostic radiological services benefit category. This copayment applies regardless of the outcome of your surgery. 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 magnetic resonance imaging (MRI) of the lumbar spine you had on June 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the abdomen and pelvis you had on April 13, 2021, and the CT scan of the chest you had on April 17, 2021.
You asked the Plan to waive the copayments for the two CT scans. You say that these CT scans should be covered in full because they were not routine. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the CT scan of the chest, the allowed amount for this service ($124.32) is less than your copayment obligation, so you are responsible for the full allowed amount for that service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for diagnostic radiology services (except ultrasounds).
You have been asked to pay a $250 copayment for each of the two CT scans. The two CT scans fall within the diagnostic radiology services (except ultrasounds) benefit category. These copayments apply regardless of the reason for the CT scans. 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 the computed tomography (CT) scan of the abdomen and pelvis you had on April 13, 2021, and the CT scan of the chest you had on April 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on June 22, 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 the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 14, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay further for the acupuncture services rendered on February 15, 2021 to May 6, 2021.

You asked the Plan to pay further for these services. You say that the services should be covered. The Plan denied your request. The Plan says the claims were processed correctly.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. The Plan contract says that there is a $10 copayment per visit for Medicare-covered acupuncture services. 

We looked at the file and Medicare rules. The file shows that you had five acupuncture visits from February 15, 2021 to May 6, 2021. You are being asked to pay a $10 copayment per visit for these services. These services fall within the Medicare-covered acupuncture services benefit category. This means that you are being asked to pay the correct amount based on your contract with the Plan. The Plan is not denying payment for these services. The Plan covered their amount and the amount you are being asked to pay is your contractual cost sharing. Therefore, we decided that the Plan does not have to pay further for the acupuncture services rendered on February 15, 2021 to May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the office visit and the hearing and
balance test you had at an otolaryngologist's office on April 22, 2021.
You asked the Plan to reduce the copayments for the office visit and the hearing and balance test. You say that
you should only have to pay the copayment for the office visit. You said that you should not pay to pay a
copayment for hearing and balance testing. The Plan denied your request. The Plan says you were charged
these copayments correctly
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for hearing and balance evaluations and a $45 copayment for office visits with a specialist.
You have been asked to pay a $45 copayment for the office visit and a $45 copayment for the hearing and
balance test. Your Evidence of Coverage clearly states that if you receive diagnostic services during an office
visit that a separate copayment will apply. This means that you have been asked to pay the correct amounts
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 reduce the copayments for the office
visit and the hearing and balance test you had at an otolaryngologist's office on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0140, D0220) received on June 16, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D0140, D0220) received on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the visit you had at an oncologist's office on May 12, 2021.
You asked the Plan to reduce the copayment for the oncology visit. You say that because you only saw a nurse practitioner and not a doctor, you should only have to pay a $5 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist visits with a physician or practitioner. You have been asked to pay a $40 copayment for the oncology visit. Your Evidence of Coverage states that this specialist copayment applies to physician and practitioner services.
There is no provision in your contract stating that nurse practitioner services only have a $5 copayment, unless the nurse practitioner is a primary care provider. 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 reduce the copayment for the visit you had at an oncologist's office on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
You asked the Plan to pre-approve a CT scan of the heart. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 a CT scan of the heart. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on May 4, 2021.
You asked the Plan to pay for an eye refraction. You say that you were advised by your primary care doctor to receive a vision check. The Plan denied your request. The Plan says eye refractions are only covered by the plan if performed by a participating vision provider and performed as a routine vision screening.
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 these services when it is performed as a routine screening by a participating provider. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. An eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May
11, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you went to the Veterans'
Affairs (VA) clinic because you were unable to use one of your legs. You said that the doctor sent you to the
emergency room via ambulance. You stated that the services you received at the emergency room could have
been done by the VA doctor, so you don't think you should have to pay this bill. The Plan denied your request.
The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for ambulance services.

You have been asked to pay a $150 copayment for ambulance services. This copayment applies regardless of
the reason for the transport. 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 ambulance services you
received on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided May 22, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450) provided May 22, 2021.