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

We decided that the Plan does not have to waive the copayment for the outpatient diagnostic mammogram services provided on July 21, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that you had a mammogram screening on July 8, 2021 and was asked to go back due to a possible abnormal finding. The claims were filed as a diagnostic instead of a routine screening causing the 20% coinsurance to apply. The Plan denied your request. The Plan says this claim was processed with the correct cost share applied per the 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 20% of the cost for diagnostic procedures and tests for Outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay $51.06 for the diagnostic services. The diagnostic service 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 the outpatient diagnostic mammogram services provided on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on November 20, 2020.

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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that payment for these services are always bundled into payment for other services not specified. 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 99100 provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care, per day (99220) rendered by the out-of-network (OON) provider on December 18, 2020.

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 initial observation care, per day (99220) rendered by the out-of-network (OON) provider on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on May 17, 2021.

You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 copayment for each specialist visit. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist visit on May 17, 2021. You have been asked to pay a $20 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner services 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 specialist visit provided on May 17, 2021.

Your complaint about feeling as though this should not be considered an office visit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided May 17, 2021.
You asked the Plan to pay for the vision services. You say that you were diagnosed with type II diabetes and the doctor sent you for the eye exam to check for damage from diabetes. It was a medical need from what she had said otherwise you would not have had it. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
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. Refraction services is not covered under the Plan under any condition. We looked at the file and the Plan's rules. Refraction services is not covered under the Plan under any condition. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided May 17, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided February 8, 2021 to February 22, 2021.
You asked the Plan to pay for the acupuncture services. You say that you were not aware that acupuncture was only for chronic low back pain. The Plan denied your request.
The Plan says acupuncture for peripheral neuropathy is not covered under the Plan benefits. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
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. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture for peripheral neuropathy is not covered under the Plan benefits. The provider also is not a Medicare participating provider. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided February 8, 2021 to February 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 16, 2021, through March 26, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day, for days 1-5 for in-network inpatient hospital care. 

The enrollee has been asked to pay $1,500 ($300 copayment x 5 days) for the inpatient hospital care provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.

This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 16, 2021, through March 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and caries risk assessment (D0603) provided on May 19, 2021.

You asked the Plan to pay for the adjunctive pre-diagnostic test and caries risk assessment. You say that the provider you were treated by was filling in for the regular in-network providers who were out that day. The Plan denied your request. The Plan says these services are not covered.

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 the adjunctive pre-diagnostic test (D0431) and caries risk assessment (D0603) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on September 1, 2020. 
 
You asked the Plan to pay for lab tests. You say that you feel the Plan's denial is in error and should be 
reversed. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because 
the documentation submitted does not support the Place of Service (POS) code billed on this claim. 
 
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 documentation shows that the sample for this testing was taken 
in a nursing facility setting, therefore the POS code 11 - indicating an office setting - is not appropriate for this 
claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory testing provided on September 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar x-ray provided on January 6, 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 72110 is radiologic examination, spine, lumbosacral;
minimum of 4 views. We find that CPT code 72110 is not supported in the medical record. Specifically, the
records do not include a report for the services at issue. 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 the lumbar x-ray provided on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies represented by code 99072 provided on February 18, 2021.
You asked the Plan to pay for code 99072. 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 providers must report services correctly.
We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided
that the Plan does not have to pay for the additional supplies represented by code 99072 provided on February
18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2020, V2303, V2750, V2304) provided on 
February 2, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that you know you have a $150 eyewear benefit 
allowance every two years, and it has been almost three years since you purchased eyeglasses. The Plan denied 
your request. The Plan says the $150 benefit allowance was paid, but the remaining cost of the eyewear was 
denied. 
 
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 will pay up to $150 for eyewear every 24 months. If the eyewear you purchase costs more 
than $150, you pay the difference. 
 
We looked at the file and the Plan's rules. Documentation shows that the original cost of the eyewear was $564. 
The Plan paid the full $150 allowance and you are responsible for the remaining cost ($564 - $150 = $414). 
Based on this information, we decided that you have been asked to pay the correct amount based on your 
contract with the Plan. The Plan has already paid the full $150 allowance. Therefore, we decided that the Plan 
does not have to pay for the eyeglasses (V2020, V2303, V2750, V2304) provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on May 21, 2021.
You asked the Plan to pay for the eye refraction. You say that this service was necessary, and you did not
realize you could only have this service once per year. The Plan denied your request. The Plan says this service
may only be covered once per year. You previously had this service in October of 2020, and it was covered by
the Plan at that time. The date in question is less than a year after this previous claim and remains denied.
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 once per year.
We looked at the file and the Plan's rules. You previously had this service less than a year before the date in
question, and the refraction was covered at that time. 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 May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a home mechanical ventilator (E0466). 
 
You asked the Plan to pre-approve a mechanical ventilator. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says that rules for coverage for the requested item 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 mechanical ventilator. Our reviewer 
says that the requested item is medically necessary and reasonable in this case. Our physician reviewer found 
that the enrollee has chronic respiratory failure as the result of COPD. It is documented and supported in the 
medical record that nocturnal and daytime volume ventilation is needed for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a mechanical ventilator have been met. Therefore, we decided that the Plan has 
to pre-approve a home mechanical ventilator (E0466).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided to the enrollee March 11, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the 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. 

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. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided to the enrollee March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
April 15, 2021, to April 20, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that while in surgery, the doctor
needed an x-ray to see if everything was places right. The Plan denied your request. The Plan says the claim
was processed with the correct copayments applied per the 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 $295 per
day for days 1-4 for Inpatient hospital care.
You have been asked to pay $1,180.00 copayment ($295 x 4 days) for the inpatient services. The inpatient
services fall within the Inpatient hospital care 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 inpatient hospital services provided April 15, 2021, to April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (70450) provided to the enrollee on June 6, 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 an appropriate modifier was not 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 without the appropriate modifier. 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 imaging services (70450) provided to the enrollee on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device provided to the 
enrollee April 30, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the 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 is a preventive service. Claims for E0675 will be denied as 
not reasonable and necessary.   
 
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. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for an intermittent limb compression device provided to the enrollee April 
30, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90832) provided on March 9, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says that rules for payment have not been met because there is no documentation of consultation with the enrollee's attending or primary care physician.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician and to notify the physician within a reasonable time that he or she is furnishing services to the enrollee. 

We looked at the file and Medicare rules. The medical record documents that the provider has notified the enrollee's attending physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. Therefore, we decided that the Plan has to pay for psychotherapy services (90832) provided on March 9, 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.