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

We decided that the Plan does not have to pay for the laboratory services rendered on February 23, 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 must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2025, V2750, V2781) provided on
August 30, 2021.
You asked the Plan to pay for the eyeglasses. You say that you purchased these services from an in-network provider and should receive reimbursement. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's specified network. Supplemental vision services received from out-of-network providers are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a network optical provider. We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's routine vision network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2025, V2750, V2781) provided on August 30, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy electrical pump (E2402) provided on July 9, 2021.  You asked the Plan to waive the coinsurance for a negative pressure wound therapy electrical pump. You say that nobody informed you about this cost-sharing. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment.   You have been asked to pay $218.40, or 20% of the Medicare-allowed charge of $1,092, for a negative pressure wound therapy electrical pump. A negative pressure wound therapy electrical pump falls within the "Durable medical equipment (DME) and related 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 coinsurance for a negative pressure wound therapy electrical pump (E2402) provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on August 25, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99214 (office visit) and 98928 (osteopathic manipulation). Code 99214 is a column II code with a modifier indicator of 1 when billed with column I code 98928. Code 99214 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on August 25, 2021
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued SNF services. You say that the records provided support the need for continued SNF care. The Plan denied your request. The Plan says continued SNF care is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy, speech therapy, and occupational therapy in the SNF. By the dates in question the enrollee was at a standby assist to minimal assist level with functional mobility including gait to 60 feet. The enrollee required varying assist with activities of daily living. She tolerated a mechanical soft diet and thin liquids.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided on July 26, 2021.  You asked the Plan to waive the copayment for the ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. You say that the Plan's coverage booklet states there is a $35.00 copayment for the exam. The Plan denied your request. The Plan says the member's 2021 Evidence of Coverage states there is a $65.00 copay for each covered diagnostic procedure or test at a network doctor's office.  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 $65.00 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies, for each covered diagnostic procedure or test at a network doctor's office  You have been asked to pay a $65.00 copayment for the ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation. The ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation 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 ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation (92136) provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021.  You asked the Plan to pay for the laboratory services. 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.    We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for contact lenses provided on  September 1, 2021.  You asked the Plan to pay an additional amount for contact lenses. The Plan denied your request. The Plan says that the Plan paid the Plan's share in the amount of $250 directly to the provider.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum eyewear allowance of $250 directly to the provider. Therefore, we decided that the Plan does not have to pay an additional amount for contact lenses provided on September 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride, excluding varnish, (D1208) provided on March 17, 2021.  You asked the Plan to pay for the dental service. You say that you advised the provider that you only wanted services that would be covered. You say that you received a bill for $34.86. The Plan denied your request. The Plan says topical application of fluoride, excluding varnish, is not listed as a covered service.  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 topical application of fluoride, excluding varnish, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride, excluding varnish, (D1208) provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a grab bar provided from May 20, 2021, through May 25, 2021.  You asked the Plan to pay for a grab bar. You say that your provider at rehab notified you of the need to have home modifications due to having a broken leg. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature.   While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a grab bar provided from May 20, 2021, through May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for remote intraoperative neurophysiology monitoring (95941) provided on December 30, 2020.  You asked the Plan to pay for remote intraoperative neurophysiology monitoring. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Code 95941 has a status indicator of "I" on the Physician Fee Schedule. This means that code 95941 is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of remote intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for remote intraoperative neurophysiology monitoring (95941) provided on December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy administration (96401) and the Herceptin Hylecta injection (J9356) provided on August 10, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy drugs provided at a specialist office or outpatient hospital.
You have been asked to pay a $480.61 coinsurance for the chemotherapy service provided at an outpatient hospital. The Plan's allowable charge for this service was $4,397.73 in which $3,917.12 was paid for. The remaining balance and member liability in this case is $480.61, which is less than the applicable coinsurance. This claim was processed at the in-network benefit level. 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 the chemotherapy administration (96401) and the Herceptin Hylecta injection (J9356) provided on
August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery (66984) provided on
June 18, 2021, at an ambulatory surgical center.
You asked the Plan to waive the copayment for a cataract surgery. You say that you were given wrong
information in regard to cataract surgery. The Plan denied your request. The Plan says the correct 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 $275
copayment for outpatient surgery services provided at an ambulatory surgical center.
You have been asked to pay a $275 copayment for a cataract surgery. A cataract surgery falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 a cataract surgery (66984)
provided on June 18, 2021, at an ambulatory surgical center.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities
from representatives of the Plan 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 anesthesia services (00140) provided on March 30, 2021.  You asked the Plan to pay for code 00140. 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 as 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 00140 is Anesthesia for procedures on eye; not otherwise specified.  We find that CPT code 00140 is not supported in the medical record. Specifically, the file shows that the anesthesia services (00140) were performed for code 66984. Per CPT guidelines, procedures should always be coded to the highest specificity. In this case, a cataract extraction and lens prosthesis were performed. CPT code 00140 is an inappropriate code to report, as a more specific code exists for the service performed. Based on this information, we decided that Medicare rules for coverage of code 00140 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00140) provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for extractions (D7140) provided by a participating provider on July 29, 2021.  You asked the Plan to pay for extractions. You say that you misunderstood the benefits. The Plan denied your request. The Plan says the correct charges have been applied.  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 covers two extractions a year.  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions have already been met. Two of the extractions provided on this date of service was covered with a total amount of $84. The other eight extractions were denied due to the benefit limit has already been exhausted for D7140. Therefore, we decided that the Plan does not have to pay for extractions (D7140) provided by a participating provider on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Laser treatment for inflammatory skin disease (psoriasis) (96921) provided on July 6, 2021.  You asked the Plan to pay for code 96921. 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 as 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 96921 is Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm.  We find that CPT code 96921 is not supported in the medical record. Specifically, codes 96920-96922 should not be reported for treatment of any inflammatory disease other than psoriasis. The file shows the diagnosis code billed with code 96921 is not psoriasis. Based on this information, we decided that Medicare rules for coverage of code 96921 have not been met. Therefore, we decided that the Plan does not have to pay for the Laser treatment for inflammatory skin disease (psoriasis) (96921) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on August 18, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you believe that you should not be charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 covers a comprehensive oral evaluation once per calendar yea/.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have already been exhausted. Evidence was provided to show that a comprehensive oral evaluation was provided on January 11, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on
August 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided on July 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the PT services. You say that the enrollee was approved for 8 visits of physical therapy. You also say that this should be covered. The Plan denied your request. The Plan says the provider should have verified the enrollee's eligibility, health benefits, and obtained authorization prior to rendering the services.
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 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 physical therapy (PT) services provided on July 13, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2021.  You asked the Plan to pay for the laboratory services. 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 as billed.  The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT codes describing the component test results.  We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion tomographic imaging
(78452) provided on August 18, 2021.
You asked the Plan to waive the copayment for myocardial perfusion tomographic imaging. You say that you
were misled and never told that the service at issue would have a copayment. The Plan denied your request.
The Plan says the correct 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 $325
copayment for Medicare-covered diagnostic radiology services that are not ultrasounds.
You have been asked to pay a $325 copayment for myocardial perfusion tomographic imaging. Myocardial
perfusion tomographic imaging 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 myocardial perfusion
tomographic imaging (78452) provided on August 18, 2021.
Your complaint about not receiving adequate information from the provider about your cost-sharing
responsibilities 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.