Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for intraoral, complete series of radiographic images (D0210) provided on October 5, 2021.  You asked the Plan to pay for complete series of radiographic images. You say that this is the third time that you have been given misinformation by member services on a contracted provider. You feel like there is a disconnect between contracts and the provider directory.  You would like the claims to be paid correctly since the provider directory is incorrect. The Plan denied your request. The Plan says the requested service is not a covered benefit with your Plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral, complete series of radiographic images (D0210) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 13, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you were billed multiple times for the same procedure. The Plan denied your request. The Plan says they reprocessed and approved the correct copayment for the services rendered. The proper copayment has now been applied for this service.

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 $40 copayment for Physician specialist services.

You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the Physician/Practitioner services, including doctor's office 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 a specialist visit provided on August 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 12, 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 provider did not bill as required by Medicare coding regulations.  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 70551. 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 provided to the enrollee on September 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for computerized ophthalmic diagnostic imaging (92133) provided on September 15, 2021.  

You asked the Plan to waive the copayment for computerized ophthalmic diagnostic imaging. You say that you are being charged more for the same service you received last year with another provider. 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 $30 copayment for Medicare-covered non-radiological diagnostic services.   

You have been asked to pay a $30 copayment for computerized ophthalmic diagnostic imaging. Computerized ophthalmic diagnostic 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 computerized ophthalmic diagnostic imaging (92133) provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for DME provided on May 5, 2021.

You asked the Plan to pay for the DME. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for DME provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an endodontic therapy (D3330) for tooth #18.  You asked the Plan to pre-approve the endodontic therapy. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.  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, endodontic therapy (D3330) is limited to one procedure per tooth per lifetime of the member.        The record shows that you received an endodontic therapy (D3330) on tooth #18 on December 9, 2020 and your endodontic therapy (D3330) benefit for tooth #18 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an endodontic therapy (D3330) for tooth #18.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 7, 2021.  You asked the Plan to waive the copayment for a specialist office visit. You say that the copayment charged was wrong and according to your plan you should only be charged a $10 copayment. The Plan denied your request. The Plan says the proper copayment was applied for this service according to the plan of the enrollees.  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 medical care or surgery services in a Specialty Physician's office.     You have been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls within the Physician/Practitioner services, including doctor's office 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 a specialist office visit provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for angiographies (75710-59, 75774-59) provided on July 11, 2021.  

You asked the Plan to pay for angiographies. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says the use of modifier -59 is not supported.  

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.      

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the record shows that the services at issue were performed during the same encounter as the primary procedures. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for angiographies (75710-59, 75774-59) provided on July 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 15, 2021.  You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you had a hypoglycemic seizure and could not move or get your Glucagon. You also say that you needed a medically trained person to give you your Glucagon and did not need to go to the hospital. The Plan denied your request. The Plan says no ambulance transportation occurred on this date of service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on August 15, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (procedure code 93926) provided to the enrollee on September 14, 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 procedure code has a bilateral indicator of "0."

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 93926 is "Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study." 

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 provider reported 2 units Current Procedural Terminology (CPT) 93926: Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study. This service should be reported with the bilateral procedural code with 1 unit. A bilateral. Procedure report documents "common femoral, superficial femoral popliteal arteries are widely patient." This procedure supports a complete study.

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 radiology services (procedure code 93926) provided to the enrollee on September 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 6 additional home health physical therapy (PT) visits (G0151).  You asked the Plan to pre-approve 6 additional home health visits. You say that you need these services. The Plan denied your request. The Plan says the additional visits are not medically necessary.  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 6 additional home health visits. Our reviewer says that the 6 additional home health visits are not medically necessary. Our physician reviewer found the enrollee does not have documented, ongoing, skilled therapy needs. The reviewer found that the enrollee appears to be at her baseline level of function. The reviewer found that the 5 approved visits for maintenance therapy (five visits in sixty days), which should be able to monitor any ongoing durable medical equipment (DME) needs or changes.  Therefore, the reviewer found that the requested additional 6 skilled therapy visits are not medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional home health visits have not been met. Specifically, the file shows that the enrollee does not have documented, ongoing, skilled therapy needs. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health physical therapy (PT) visits (G0151).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) provided on August 29, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as you did not mean to enroll into this plan. The Plan denied your request. The Plan says the cost-sharing 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency care.        You have been asked to pay a $90 copayment for an emergency room visit. The Plan's contract states that the copayment for emergency care is only waived when you are admitted not the hospital within 24 hours for the same condition. 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 emergency room visit (99285) provided on August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015) provided on November 1, 2021.  You asked the Plan to pay for the eye refraction. You say that you were not aware this service would not be covered, and it is the policy of the provider's office to administer this service for all new patients. The Plan denied your request. The Plan says Medicare does not cover eye refractions. The Plan offers a supplemental benefit to cover eye refractions when they are performed by a provider in the Plan's routine vision network as part of a routine screening. The refraction in this case was provided as part of a medical (non-routine) eye exam, and therefore the Plan's rules for coverage of an eye refraction have not been met.  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 performed by a routine vision provider as part of a routine eye exam.  We looked at the file and the Plan's rules. Medical records show that you presented with glare in both eyes and blurry vision. You were assessed for cataracts, and the eye exam was billed with medical diagnoses. The eye exam in this case was not a routine exam. Eye refractions are not covered for medical purposes and are only eligible for coverage when they are received as part of a routine eye exam performed by a provider in the Plan's specified routine vision vendor network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory service (81401) rendered by the out-of-network (OON) provider on January 4, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81401) rendered by the out-of-network (OON) provider on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) and Radiologic examination, spine, lumbosacral (72100) provided March 29, 2021.

You asked the Plan to pay for the chiropractic services. You say that your Plan says that you have coverage, but the initial visit, exam and x-ray were not covered. How will the doctor know what to treat if she doesn't do the exam. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) and Radiologic examination, spine, lumbosacral (72100) provided March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on August 19, 2021.  

You asked the Plan to waive the copayment for an EKG. You say that you were told you reached your limit on EKG'S and the service was denied. The Plan denied your request. The Plan says the service is a covered benefit, and 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 $20 copayment for Medicare-covered non-radiological diagnostic services. The total amount billed for the EKG was $14.74 which is lesser than the copayment amount of $20. Therefore, the copayment amount was only $14.74. 

You have been asked to pay a $14.74 copayment for an EKG. An 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 August 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for chemotherapy services provided on July 19, 2021.  You asked the Plan to waive the coinsurance for chemotherapy services. You say that you have never had to pay for chemotherapy treatment before. 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 10% coinsurance up to a $300 quarterly maximum for Medicare Part B chemotherapy drugs.    You have been asked to pay $300, or less than 10% of the Medicare-allowed charge of 3,096.43, for chemotherapy services. Chemotherapy services fall within the "Medicare Part B prescription drugs" 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 chemotherapy services provided on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 74177) provided to the enrollee on September 21, 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 provider did not bill as required by Medicare coding regulations.  

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 74177 is a column II code to column I code 74174. 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 74177) provided to the enrollee on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar epidural injection services.  You asked the Plan to pre-approve lumbar epidural injection services. You say that the records provided support the need for the requested injection services. The Plan denied your request. The Plan says the injection services requested are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that ESI injection services are covered for certain clinical criteria, including the inability to tolerate noninvasive conservative care or medical documentation of failure to respond to four weeks of noninvasive conservative care.  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 lumbar epidural injection services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic low back pain with radicular signs. The enrollee takes Gabapentin and Norco for pain. The enrollee has done physical therapy with noted improvement in pain and increased ability to do activities. The MRI shows degenerative disc disease and mild spinal stenosis and neuroforminal stenosis. Because the enrollee has responded well to physical therapy and medications, she does not meet the criteria of having the inability to tolerate or a failure to respond to noninvasive conservative care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injection services.