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

We decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on June 7, 2021, billed with codes 95885, 95937, and 95907.

You asked the Plan to pay for the IONM services as billed. You say that this is correctly coded. The Plan denied your request. The Plan says the denied codes are not supported.

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 95907 is nerve conduction studies; 1-2 studies. The definition of 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 

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 IONM services as billed. Our reviewer says that the codes billed on this claim are not supported. Our reviewer found the procedure report does document nerve conduction studies, which measures amplitude and latency/velocity. Documentation describes "pedicle screw stimulation", CPT 95907 is an incorrect code to report for this procedure. Per CPT code description, this procedure in done with nerve conduction studies. Procedure report does not include documentation of nerve conduction studies. Documentation describes neuromuscular junction monitoring is being reported for train of four testing. This is the incorrect code to report for this procedure. Train of four testing should not be reported separately, as this code is inclusive to intraoperative neuromonitoring. 

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 IONM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring (IONM) services provided on June 7, 2021, billed with codes 95885, 95937, and 95907.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the visit with an optometrist you had on August 23, 2021.
You asked the Plan to waive the copayment for the visit with an optometrist. You say that you and your husband had eye exams on the same day, and he was not charged a copayment. You said that you should not have a copayment either. The Plan denied your request. The Plan says that this was not billed as a routine eye exam, so the specialist copayment applies.
The burden is on the Plan to prove why its assessment of cost sharing is correct. In addition, the Plan is obligated to provide us with all of the documentation and citations needed to support their decision. They have failed to do both in this case. First, the Plan contends that you were charged a specialist copayment of $20 correctly because this was not billed as a routine eye exam. We agree that this was not billed as a routine eye exam. However, the Evidence of Coverage lays out cost sharing obligations for medical (i.e., non-routine) eye exams as well, and according to this document, there is no cost sharing for medical eye exams. It is not clear why the Plan is assessing cost sharing for this service.
Second, in its very limited case file submitted to us for review, the only section of the Evidence of Coverage that the Plan submitted to support its decision was page 72. This page only references physician services provided in an inpatient setting and has absolutely nothing to do with the services you received. The Plan failed to provide the full copy of the Evidence of Coverage in the case file (as they are required to do). We were able to go online and locate the full version of the Evidence of Coverage to determine what the appropriate cost sharing should have been. As noted above, the appropriate cost sharing for non-routine eye exams is $0 in accordance with the Vision Care section of your Evidence of Coverage.
The Plan says you must pay a $20 copayment for the visit with an optometrist. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the visit with an optometrist. Therefore, we decided that the Plan has to waive the copayment for the visit with an optometrist you had on August 23, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for over the counter (OTC) supplements, Istonix OPC-3 provided on April 12, 2021.

You asked the Plan to reimburse you for OTC supplements, Istonix OPC-3. The Plan denied your request. The Plan says the Medicare Managed Care Manual specifically prohibits Medicare Advantage plans from covering "Alternative medicines" under an OTC benefit. The Managed Care Manual defines these items as homeopathic and alternative medicines including botanicals, herbals, probiotics and nutraceuticals.

The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list. Ineligible items include alternative medicines such as botanicals, herbals, probiotics and nutraceuticals.

We looked at the file and Medicare rules. The file shows that OTC items must be included on the Plan's allowed items list. Ineligible items include alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. Therefore, we decided that the Plan does not have to reimburse you for over the counter (OTC) supplements, Istonix OPC-3 provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a guided tissue regeneration (D4266) provided by a participating provider on August 10, 2021.

You asked the Plan to pay for a guided tissue regeneration. You say that you do not feel like you owe this. The Plan denied your request. The Plan says they made a one-time exception, leaving the enrollee with a $10 remaining balance.

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. The Plan has approved a one-time exception to allow benefits up to the remaining dental allowance.

We looked at the file and Medicare rules. The EOC states that the enrollee is responsible for 100% of the charges beyond the $1,000 allowance for dental services; therefore, you are being asked to pay $10 due to exceeding your dental allowance.

Based on this information, we decided that the Plan's rules for coverage of a guided tissue regeneration have not been met. Therefore, we decided that the Plan does not have to pay for a guided tissue regeneration (D4266) provided by a participating provider on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound debridement procedures you had at an outpatient hospital facility from May 12, 2021, to August 6, 2021.

You asked the Plan to waive the copayments for the wound debridement procedures. You say that every time you went to the clinic, you were charged a high copayment because the clinic is part of the hospital. You stated that you are willing to pay your fair share, but you are being charged a lot for these services. 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 $225 copayment for visits to an outpatient hospital facility. 

You have been asked to pay a $225 copayment for the wound debridement procedures. The wound
debridement procedures occurred at an outpatient hospital facility, so these services fall within the visits to an outpatient hospital facility 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 copayments for the wound debridement procedures you had at an outpatient hospital facility from May 12, 2021, to August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on August 19, 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 a modifier was not billed on the claim.
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 is a column II code to column I code 70496. 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 imaging services (procedure code 70450) provided to the enrollee on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring) (99190) autologous blood or component, collection processing and storage (86891) red blood cells, washed, each unit (P9022) provided June 9, 2021.

You asked the Plan to pay for the perfusionist services. You say that the enrollee did not have a choice of perfusion providers or prior knowledge of your services being out of network because your service was arranged directly with the surgeon and facility. The Plan denied your request. The Plan says services is included in the facility claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CMS follows a Prospective Payment System (PPS) where Medicare payment is based on a predetermined, fixed amount payable to a facility for inpatient or outpatient services. With these payment systems, all costs associated with nonphysician services are deemed included in the payment to the facility and not considered separately reimbursable. In this case, payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of the perfusionist services have not been met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring) (99190) autologous blood or component, collection processing and storage (86891) red blood cells, washed, each unit (P9022) provided June 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Fluid Flow amniotic fluid grafting injection provided on June 21, 2021, billed with code Q4206.
You asked the Plan to pay for the Fluid Flow injection. You say that this was medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says this is experimental and cannot be covered.
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 Fluid Flow injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has low back pain with right tensor fascina latae muscle pain.
She received a Fluid Flow allograft injection. This is considered an experimental medication at this time and is the subject of a Food and Drug Administration (FDA) warning. Therefore, the procedure was not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Fluid Flow injection have not been met. Therefore, we decided that the Plan does not have to pay for the Fluid Flow amniotic fluid grafting injection provided on June 21, 2021, billed with code Q4206.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic services coded as 97110 provided on
December 17, 2019
You asked the Plan to pay for the therapeutic services. You say that the documentation provided supports the
code as billed. The Plan denied your request. The Plan says the records do not substantiate the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
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 therapeutic services. Our reviewer says that the
documentation does not support the services as billed. Our reviewer found the medical records document that
service was performed in a home health or hospice setting. 97110 is not the most appropriate code to represent
the service performed. There is a more appropriated Healthcare Common Procedure Coding System code to use to bill this service; therefore, this service is not eligible for reimbursement consideration. 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 therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic services coded as 97110 provided on December 17, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services billed with procedure code 88121 for date of service July 23, 2021.

You asked the Plan to pay for procedure code 88121.. You say that coding edits and the diagnosis support medical necessity. The Plan denied your request. The Plan says this test was ordered for screening purposes, so it is not 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, procedure code 88121., was requested solely for screening purposes. This is confirmed by the fact that the patient was asymptomatic, and you billed with an asymptomatic diagnosis code. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services billed with procedure code 88121 for date of service July 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right-knee brace (L1851) and suspension sleeve (L2397) provided on August 11, 2021.

You asked the Plan to pay for a right-knee brace and suspension sleeve. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested items have not been met.

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 a right-knee brace and suspension sleeve. Our reviewer says that the items at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that the enrollee meets criteria for a right -knee brace. Provided records do not document knee instability on examination or a recent injury to or a surgical procedure on the knee(s). There is no documentation that the suspension sleeve meets Medicare criteria for reasonable and necessary in this case. 

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 right -knee brace and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for a right-knee brace (L1851) and suspension sleeve (L2397) provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite (D2394) for tooth # 2 provided on August 10, 2021.

You asked the Plan to pay for the dental service. You say that you received the least expensive procedure. You also say that this should be covered in full. The Plan denied your request. The Plan says the resin based composite for a back tooth is paid at the benefit of an amalgam. The Plan also says that the claim was processed correctly.

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 an resin based composites are listed as covered, resin based composites for back teeth are paid at the benefit of an amalgam. The record shows that tooth # 2 is a back tooth. Additionally, the Evidence of Coverage clearly states this and that you are responsible for the difference up to the contracted amount. Therefore, we decided that the Plan does not have to pay for the resin based composite (D2394) for tooth # 2 provided on August 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on December 15, 2020.

You asked the Plan to pay for the ground mileage and emergency ambulance transportation. You say that according to Medicare records, the enrollee's hospice coverage was revoked on December 14, 2020. You also say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on December 14, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0427) provided on December 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper endoscopy (43249) provided on September 9, 2021.

You asked the Plan to waive the copayment for the endoscopy procedure. You say that you should have a $0 copayment for these services, because you had a colonoscopy. The Plan denied your request. The Plan says the colonoscopy provided on the same date was processed with a $0 copayment, but you also had an endoscopy procedure. The endoscopy is classified as an outpatient surgical procedure and was provided in an ambulatory surgical center. This claim was processed in accordance with your contract.

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 $175 copayment for ambulatory surgical center visits. 

You have been asked to pay a $175 copayment for the endoscopy procedure. The endoscopy procedure falls within the ambulatory surgical center visits 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 upper endoscopy (43249) provided on September 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vectibix, Fluorouracil, Leucovorin calcium, and Oxaliplatin.

You asked the Plan to pre-approve Vectibix, Fluorouracil, Leucovorin calcium, and Oxaliplatin. You say that the medications 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. 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 Vectibix, Fluorouracil, Leucovorin calcium, and Oxaliplatin. Our reviewer says that the medications are not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. 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 Vectibix, Fluorouracil, Leucovorin calcium, and Oxaliplatin have not been met. Therefore, we decided that the Plan does not have to pre-approve Vectibix, Fluorouracil, Leucovorin calcium, and Oxaliplatin.