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

 We decided that the Plan does not have to pay for injection services (procedure code 64447, 64999) provided to the enrollee on March 31, 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 the records do not support 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 denied codes is:  

CPT 64447:  

Injection(s), anesthetic agent(s) and/or steroid; femoral nerve  

CPT 64999:  

Unlisted procedure, nervous system  

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the anesthesia report describes two anesthetic agents given - one in the femoral nerve, and one in sciatic nerve. If the provider is reporting the unlisted procedure for sciatic nerve injection, there is a more specific code to report for this procedure. However, the documentation does not support the modifier LT reported for these procedures, as laterality is not documented. Additionally, the provider reported CPT 64999 as an unlisted procedure with an XU and LT modifier. The anesthesia report does not include documentation that an unlisted procedure was performed, or documentation of what the unlisted procedure code is being reported for.  

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 services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (procedure code 64447, 64999) provided to the enrollee on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the pain management visit with a nurse practitioner provided on July 12, 2021.  You asked the Plan to waive the copayment for the pain management office visit. You say that you have never been charged a copayment for these visits before, and the provider is not a credentialed specialist. You feel this was applied incorrectly. The Plan denied your request. The Plan says this was applied correctly for a pain management evaluation.  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 $35 copayment for office visits to a specialist.   You have been asked to pay a $35 copayment for the pain management office visit. The pain management office visit falls within the office visits to a specialist benefit category. Although you were seen by a nurse practitioner (NP), NPs who work under a specialist are considered to be a specialist for billing purposes. 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 pain management visit with a nurse practitioner provided on July 12, 2021.
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to waive the cost sharing for the emergency department (ED) visit provided on June 16, 2021.  

You asked the Plan to waive the cost sharing for the ED visit. You say that you do not feel that this copayment should be applied because the enrollee was not actually seen in the ED on this date. You state that after signing in, you realized it was too hot for you to wait outside, and the enrollee told ED staff you would be leaving. You state you were told there would be no charge. The Plan denied your request. The Plan says that the $70 copayment is correctly applied for an ED visit. It is noted that the claims department cannot confirm whether services took place.  

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. The Plan did not attempt to obtain records from the facility to ascertain whether you were seen by medical staff at the ED at the facility in question. Although you may have signed in, there is no evidence that you were triaged or provided with any medical services. You state this did not occur. Without records, the Plan has not supported that the application of a copayment for these services is correct. Therefore, we decided that the Plan has to waive the cost sharing for the emergency department (ED) visit provided on June 16, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telephone assessment provided on October 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the OON telephone assessment. You say that you do not feel this should have been billed because you did not request to be called and it was not necessary. You feel this should have been directed to your primary care physician. The Plan denied your request. The Plan says this was provided out of network without approval. No payment can be made. Additionally, you should not be charged for this service since it would be included in the surgical payment.  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 telephone assessment provided on October 8, 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 July 2, 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 there is no evidence of an established relationship between the member and the ordering physician.  

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.       

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional units of ambulance services (A0425, A0429) provided to the enrollee on December 22, 2020.  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 the submitted documentation supports one unit each of A0425 and A0429, which was previously approved and paid.  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 the denied codes is:  A0425:  Ground mileage, per statute mile  A0429:  Ambulance service, basic life support, emergency transport (bls-emergency)  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found a claim for this transportation was already submitted and paid with an incorrect policy group number and was resubmitted with the correct information. As this review is to be determined based on clinical information, not submission error, it will be counted as a duplicate submission for the same transportation services on the same date which is redundant and not medically necessary. Administrative corrections can be worked out separately as this claim has already been paid.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for additional units of ambulance services (A0425, A0429) provided to the enrollee on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on May 6, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says this provider is out-of-network and the hearing aids provided were not authorized.  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 did not pre-approve the hearing aids. We found no exception that would require the Plan to pay for the hearing aids. Therefore, we decided that the Plan does not have to pay for hearing aids provided on May 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy services.  

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show that the special skills of a physical therapist are required.   

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation doesn't support that you require additional skilled rehab services to provide treatment that is medically necessary. You do not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The approved physical therapy visits are adequate to establish a home exercise program. The requested home health services are not medically 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for laboratory services provided to the enrollee on June 2, 2021.  

You asked the Plan to pay for the services. You say that the laboratory does not have direct access or interaction with patients prior to performing the testing. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer if not previously done. Validated molecular testing should be performed in a Clinical Laboratory Improvement Amendments (CLIA)-approved facility using the most recent available tumor tissue. Testing should include at least: BRCA1/2, homologous recombination pathway genes, and microsatellite instability or DNA mismatch repair. Molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. FoundationOne is a well-established provider of molecular profiling. The service was reasonable and medically necessary. The Plan denied your request. The Plan says that the enrollee stated she would not do a clinical trial, and testing is not used for on or off label prescribing.  

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified.  

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 services have been met. Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on June 2, 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 pay for miscellaneous vision item or service (V2799) provided on September 29, 2021.  You asked the Plan to pay for the miscellaneous vision item or service. The Plan denied your request. The Plan says this vision service is not covered by your Plan.  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 vision benefit does not cover a miscellaneous vision item or service. Therefore, we decided that the Plan does not have to pay for a miscellaneous vision item or service (V2799) provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the vision services (99213 and 92285) provided on August 23, 2021.  You asked the Plan to waive the copayments for the vision services. 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 vision services on the date of service at issue in this appeal. The Plan says that the correct copayments have 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 $50 copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye and a $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests.  We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physician services for vision care and eye photography provided on August 23, 2021. You have been asked to pay a $50 copayment for the physician services. The physician services for vision care falls within the Vision care benefit category. You have also been asked to pay a $25 copayment for the eye photography. The eye photography falls 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 vision services (99213 and 92285) provided on August 23, 2021.   Your complaint about the eye photography 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gastrostomy/jejunostomy tube purchased on July 22, 2021, from a provider not certified with Medicare.  You asked the Plan to pay for the gastrostomy/jejunostomy tube. You say that you would like to be reimbursed for this equipment. The Plan denied your request. The Plan says this provider is not certified with Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the gastrostomy/jejunostomy tube purchased on July 22, 2021, from a provider not certified with Medicare.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory 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 laboratory services provided on August 19, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for unlisted molecular pathology procedure (CPT code 81479) provided to the enrollee on August 3, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.  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.  CPT 81479 - SelectMDx in males with previous negative prostate biopsy who are being considered for repeat biopsy is promising with evidence of some clinical utility to reduce unnecessary repeat prostate biopsies. There was no documented result of prior prostate biopsy. There was no documented significant interval increase in PSA level. The test at issue in this appeal, the service, 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 unlisted molecular pathology procedure (CPT code 81479) provided to the enrollee on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 2, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you were eating and bit something hard that broke your tooth. You were in severe pain and your provider was able to take care of this issue. You also say you are requesting reconsideration of this claim. The Plan denied your request. The Plan says you have exceeded your frequency limit for this 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. The Plan covers a limited oral evaluation once per calendar year.   We looked at the file and Medicare rules. The EOC confirms that you receive one limited oral evaluation per calendar year. The records show you had a limited oral evaluation on January 7, 2021; therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 2, 2021.