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

 We decided that the Plan has to reimburse you for the Ultrasonic guidance for needle placement (76942) provided on June 11, 2021  You asked the Plan to reimburse you for code 76942. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a final determination within the allotted time frame.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the file shows you are appealing code 76942 provided to you on June 11, 2021, in the amount of $1018. The Plan has not completed their due diligence in providing a complete case file for review. The Plan provided no claim for code 76942 on this date of service for this amount. We find that the Plan has not provided enough evidence to support their reasoning for denial of payment. Therefore, we decided that the Plan has to reimburse you for the Ultrasonic guidance for needle placement (76942) provided on June 11, 2021   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist visit, and the extremity studies provided from March 9, 2021, to April 7, 2021.
You asked the Plan to waive the copayments for the specialist visit and the extremity studies. 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 and radiological diagnostic services on the dates of service at issue in this appeal. The Plan says that the correct cost share 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 $10 copayment for services obtained from a specialist and a $110 copayment for radiological diagnostic services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services obtained by a specialist on March 9, 2021. You have been asked to pay a $10 copayment for the services obtained by a specialist. The specialist services fall within the Physician/Practitioner services benefit category. You have also been asked to pay a $110 copayment for the extremity study on March 9, 2021, and a $91.91 copayment for the extremity study on April 7, 2021, which is less than the contracted $110 copayment amount. The extremity studies fall within the Outpatient diagnostic tests benefit category. 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 waive the copayments for the specialist visit, and the extremity studies provided from March 9, 2021, to April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on March 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient hospital 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 outpatient hospital services provided on
March 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on  September 11, 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 service 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). Your contract with the Plan clearly says that you must pay a $50 copayment for Medicare-covered services at an urgent care facility.   You have been asked to pay a $50 copayment for the Medicare-covered office visit provided at an urgent care facility. 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 (99203) provided on  September 11, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory service (83036) provided on May 19, 2021.
You asked the Plan to pay for code 83036. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that this service is a duplicate to a different claim that has been paid for.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. The file shows the claims are not duplicates per Medicare guidelines. The claims have a different billed amount. Therefore, we decided that the Plan has to pay for the laboratory service (83036) provided on May 19, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lesion destruction (17108) provided on August 5, 2021.  You asked the Plan to pay for the lesion destruction (17108). You say that the medical records attached support the billing of this procedure and the claim should be reprocessed for additional payment. The Plan denied your request. The Plan says procedure code 17108-79 is not supported by the medical records submitted.  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 17108 is destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm.     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 lesion destruction (17108). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not include enough clear detail to confirm destruction of cutaneous vascular proliferative lesions were performed.  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 lesion destruction (17108) have not been met. Therefore, we decided that the Plan does not have to pay for the lesion destruction (17108) provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (0202U) provided August 13, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this test was performed for screening purposes and is non-covered.  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.  The test 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 lab services (0202U) provided August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the acupuncture services (97810) provided from September 9, 2021, through September 23, 2021.
You asked the Plan to waive the cost share for the acupuncture services. You say that you would like these copayments waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 $10 copayment for acupuncture services. You have been asked to pay a total cost share of $50 for the 5 separate acupuncture services you received ($10 copayment x 5 dates of service). These services fall within the Acupuncture 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 cost share for the acupuncture services (97810) provided from September 9, 2021, through September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic agent injections (64483 and 64484) provided
on August 25, 2021.
You asked the Plan to pay for the anesthetic agent injections (64483 and 64484). The Plan denied your request.
The Plan says the claim was not coded correctly for a bilateral procedure.
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 anesthetic agent injections (64483 and 64484). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that modifier 59 represents a separate procedure which was not done. The patient had a bilateral procedure at two levels and should be coded with modifier-50. 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 anesthetic agent injections (64483 and 64484) have not been met. Therefore, we decided that the Plan does not have to pay for the anesthetic agent injections (64483 and 64484) provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology services (88108) provided on July 14, 2021.
You asked the Plan to pay for cytopathology services. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as a global service.
The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the technical component (TC) of a physician pathology service provided to an inpatient or outpatient.
We looked at the file and Medicare rules. The record shows that this was provided to a hospital outpatient, but
it was not billed with a modifier to indicate only the professional component is being billed. Based on this
information, we decided that Medicare rules for coverage of cytopathology services have not been met.
Therefore, we decided that the Plan does not have to pay for cytopathology services (88108) provided on
July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the IRF services.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on March 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says prior authorization was not obtained by the provider and the Plan did not authorize any services for this provider. The Plan also says that there is no referring provider, and the rendering provider is a non-participating 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 an office visit (99213) provided on March 26, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laparoscopy (49320) provided on June 19, 2021.   You asked the Plan to pay for the laparoscopy (49320). The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  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 49320 is laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).  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 laparoscopy (49320). Our reviewer says that this does not meet the criteria for reimbursement consideration. Our reviewer found that the records submitted indicate procedure 44120 - enterectomy, resection of small intestine; single resection and anastomosis was performed on June 19, 2021. CPT 49320 has a bundled relationship with 44120, however an acceptable modifier is allowed to unbundle the services. CPT 49320 was submitted with modifier 51, but that is not an acceptable modifier to unbundle the relationship between 49320 and 44120; therefore, 49320 cannot be considered for reimbursement.   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 laparoscopy (49320) have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy (49320) provided on June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for kidney dialysis procedures (90999) rendered from June 19, 2021, to July 31, 2021.  You asked the Plan to waive the coinsurance for kidney dialysis procedures. You say that you have kidney disease and require dialysis treatment 3 times a week. You also say you cannot afford the coinsurance and you have the top insurance plan available in your area. You also say you may be forced to stop treatment because there is no way you can pay this and if you stop you can die in a matter of weeks. The Plan denied your request. The Plan says you were 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 20% coinsurance for Medicare-covered dialysis services within the service area when ordered by your primary care provider (PCP).   You have been asked to pay $62 in coinsurance, which is 20% of the allowed amount for each dialysis procedure (310 allowed amount x 20% coinsurance = $62), for a total of $1,178 ($62 coinsurance x 19 visits = $1,178). Dialysis procedures falls within the services to treat kidney disease 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 kidney dialysis procedures (90999) rendered from June 19, 2021, to July 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Darzalex Faspro.
You asked the Plan to pre-approve the Darzalex Faspro. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the Darzalex Faspro. Our reviewer says that there is no documentation that Darzalex Faspro (in combination with the Ninlaro) is Food and Drug Administration-approved for the enrollee's diagnosis. The use of Darzalex Faspro (in combination with the Ninlaro) for multiple myeloma is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer found the use of Darzalex Faspro (in combination with the Ninlaro) for multiple myeloma does not meet Medicare criteria for safe and effective and otherwise reasonable and necessary for this 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 the Darzalex Faspro have not been met. Therefore, we decided that the Plan does not have to pre-approve the Darzalex Faspro.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjacent tissue transfer (14301) provided on June 15, 2021.  You asked the Plan to pay for the adjacent tissue transfer (14301). The Plan denied your request. The Plan says procedure code 14301 would be considered inclusive to procedure code 19318.  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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.     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 adjacent tissue transfer (14301). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided indicate procedure 19318 -breast reduction was performed on June 15, 2021. CPT code 14301 is inclusive to the services performed within CPT code 19318, therefore, 14301 would not be reported separately.   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 adjacent tissue transfer (14301) have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14301) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an out-of-network oral surgeon on September 23, 2021.  You asked the Plan to pay for dental services. You say that your dental plan informed you that this provider was contracted. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by the Plan's dental benefits when performed by an out-of-network provider.  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 when performed by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network oral surgeon on September 23, 2021.