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

 We decided that the Plan does not have to pay for the special teletherapy port plan rendered on June 10, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 77321 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the special teletherapy port plan rendered on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on September 27, 2021.  You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says there is an $1,500 allowance for preventive and comprehensive dental services. The Plan also says that the allowance has been exhausted.  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 and the services are listed as covered, the $1,500 allowance has been exhausted. The record shows that the Plan paid $256 for dental services performed on March 24, 2021, and $1,244 for dental services performed on April 13, 2021. $256 + $1,244 = $1,500. Additionally, the Evidence of Coverage clearly states that you are responsible for any amount over and above the allowance amount. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network cardiology services provided to the enrollee
on October 27, 2020, and April 26, 2021.
You asked the Plan to pay for out of network services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of
network care. We overturned the Plans denial as it appeared the provider was contracted with the Plan.
The Plan requested a reopen and stated that it has been determined that the provider seen by the enrollee was
not a Plan contract provider.
The Plan is correct in this case. 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 seen by the enrollee is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services rendered. Therefore, we decided that the Plan does not have to pay for out of network cardiology
services provided to the enrollee on October 27, 2020, and April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on August 17, 2021.

You asked the Plan to pay for the services provided. 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.
Providers must report services with the appropriate CPT code. The file shows that the enrollee received a
nutria-pharmaceutical injection, billed with multiple codes. The multiple drug codes reported on this claim
refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed
using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment
cannot be made.

The records show that electrical nerve stimulation and vasopneumatic device therapy was provided. We looked
at the file and the rules. We find that the physical therapy services at issue in this case were rendered by a nurse
practitioner who is not licensed to provide physical therapy in the state where the services were provided.
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 pain management services provided on
August 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on July 30, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that the enrollee should not be charged for this because it was a non-emergency transport.  you said that a wheelchair van should have been called instead of an ambulance. The Plan denied your request. The Plan says this copayment was charged correctly.  The Plan says that because the allowed amount for the ambulance services ($285.94) is less than the copayment obligation, the enrollee is responsible for the full allowed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment for ambulance services.   The enrollee has been asked to pay a $325 copayment for the ambulance services. This copayment applies each time ambulance services are received, regardless of the reason for the transport. 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 ambulance services provided on July 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on September 13, 2021.  You asked the Plan to pay for the dental services. You say that you went in for your yearly x-ray and cleaning. You say that there was a problem with your bridge. You also say you have a broken tooth with decay under your bridge. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 plan years. The Plan says that complete series x-ray is covered once every 3 plan years. The Plan also says that the frequency limits have been exceeded.    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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on July 29, 2019, 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 comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on September 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for knee arthroscopy surgery (29876) provided on June 21,
2021.

You asked the Plan to pay for knee arthroscopy. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do
not support this code.

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 29876 is arthroscopy, knee, surgical; synovectomy,
major, 2 or more compartments.

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 knee arthroscopy. Our reviewer says that this code does not
meet the criteria for payment. Our reviewer found to support reporting code 29876 with other arthroscopy
procedures to the knee should be supported by synovectomy performed in 2 or more compartments which no
other procedure was performed, and documentation of synovial disease. The documentation submitted
describes a meniscectomy performed in the medial compartment, and synovectomy performed in the medial
gutter; subpatellar area; and lateral gutter, which would be 3 compartments of the knee. Per Medicare
guidelines code 29876 may be reported for a medically reasonable and necessary synovectomy with another
arthroscopic knee procedure on the ipsilateral knee if the synovectomy is performed in 2 compartments on
which another arthroscopic procedure is not performed. Documentation supports 2 or more compartments, that
another procedure was not performed, and a synovectomy to "clean up" a joint on which another more
extensive procedure is performed on which another more extensive procedure is performed is not separately
reportable. In this case, the provider documents significant amount of hypertrophic, hyperemic synovitis
throughout the knee. Procedure report does not include enough documentation to support pathological synovial
disease present, to support separately billing this procedure.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of knee arthroscopy have not been met. Therefore, we decided that the Plan does
not have to pay for knee arthroscopy surgery (29876) provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) infrared light therapy (97026) and medical nutrition therapy (97803) provided July 29, 2021.  You asked the Plan to pay for the acupuncture services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered under the Plan benefits. Infrared therapy is not covered by Medicare. The services were rendered by a licensed acupuncturist, not a physician.  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 rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.  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, the records do not support that the enrollee was provided medical nutrition therapy or that the enrollee suffers from renal disease or diabetes. Infrared therapy is not covered by Medicare. The services were rendered by a licensed acupuncturist, not a physician. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) infrared light therapy (97026) and medical nutrition therapy (97803) provided July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a hereditary cardiovascular risk analysis (81405, 81404, 81401) provided on January 20, 2021.  You asked the Plan to pay for a hereditary cardiovascular risk analysis. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.  We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular risk analysis have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular risk analysis (81405, 81404, 81401) provided on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on July 19, 2021.  You asked the Plan to waive the copayment for the EKG. You say that you feel that the EKG should be part of your wellness visit and you have never been charged before. 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 $0 copayment for the annual wellness visit. There may be additional cost-sharing for diagnostic testing performed during your visit.  Your contract with the Plan also clearly says that you must pay a $20 copayment for non-radiological diagnostic services, including EKGs.  You have been asked to pay $11.71, which is less than the $20 copayment for the EKG. The EKG falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an MRI provided on May 19, 2021.  You asked the Plan to waive the deductible for the MRI. You say that the services should be covered, and you don't understand why the plan hasn't paid anything. The Plan denied your request. The Plan says the deductible applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies.    The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the time the MRI was received on May 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an MRI provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visit services to be provided by an OON provider.  You asked the Plan to pre-approve office visit services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network dermatologists available to the enrollee that are located within the enrollee's service area.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.    The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visit services to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain stem (70554) provided on September 9, 2021.  You asked the Plan to pay for the MRI of the brain stem. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70553 and 70554.  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 70554 is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the brain stem (70554) provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency services provided on September 13, 2021.  You asked the Plan to waive the copayment for emergency services. You say that the enrollee should not have a copayment due to poor service. The Plan denied your request. The Plan says the proper copayment was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for In-Network Emergency Services.   You have been asked to pay a $90 copayment for emergency services. Emergency services falls within the Emergency 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 emergency services provided on September 13, 2021.   Your complaint about your experience with this provider 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: Partially Favorable

 You asked the Plan to pay for psychotherapy visits. You say that you are entitled to 80% coverage for all of the claims you have filed. The Plan says that the reimbursement amounts you are being paid are correct.  We decided that the Plan has to pay for the psychotherapy visit provided on March 24, 2021.   The Plan follows Medicare rules. Medicare rules state that code 90837 has a non-facility price of $146.67 in your locality.  You are requesting reimbursement for code 90837 on date of service March 24, 2021. The Plan's Explanation of Benefits (EOB) shows that the Plan approved coverage for this service but wrote off the entire cost of the visit to allow $0 payment. The Plan did not provide any rationale or evidence to support a denial of this visit. Therefore, the Plan has not shown that its decision to allow $0 for this Medicare-covered service is correct or justified. Therefore, we decided that the Plan has to pay for the psychotherapy visit provided on March 24, 2021.   We also decided that the Plan does not have to waive the coinsurance for the psychotherapy visits provided from February 25, 2021, to March 11, 2021.  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 50% coinsurance for out-of-network psychotherapy visits. The allowed amounts of these visits total $405.98, resulting in a coinsurance amount of $203. Therefore, the Plan reimbursed you a total amount of $202.98. Therefore, we decided that the Plan does not have to waive the coinsurance for psychotherapy visits.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 10, 2021, to August 11, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you had surgery. You say that you should not be responsible for the services rendered during surgery as you had no control. You also say that these should be covered. The Plan denied your request. The Plan says self-administered drugs are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from August 10, 2021, to August 11, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.