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

We decided that the Plan does not have to pay for the office visit (99205) provided on July 28, 2021, by a
provider who has opted out of Medicare.
You asked the Plan to pay for the office visit. You say that you believe that based on coverage rules this should
be covered. The Plan denied your request. The Plan says the provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office
visit (99205) provided on July 28, 2021, by a provider who has opted out of Medicare.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425,
A0426) provided on April 16, 2021.

You asked the Plan to waive the copayment for the ambulance transportation services. You say that the
services should be covered as they would not let you leave. The Plan denied your request. The Plan says the
cost-sharing applied correctly based on the services rendered

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 $250
copayment for Ambulance services.

You have been asked to pay a $250 copayment for a one-way ambulance transport. 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 ambulance transportation services (A0425, A0426) provided on April 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care.
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 SNF admission. Our physician reviewer
found that the enrollee does not have documented skilled nursing or skilled therapy needs. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee does not meet Medicare criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937), intraoperative neurophysiology monitoring (95941), and an electroencephalogram during coma or sleep (95822) provided on November 6, 2020.

You asked the Plan to pay for neuromuscular junction testing, intraoperative neurophysiology monitoring, and an electroencephalogram during coma or sleep. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the services at issue are not medically supported in this case.

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 neuromuscular junction testing, intraoperative neurophysiology monitoring, and an electroencephalogram during coma or sleep. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the neuromuscular junction testing was not done in a manner consistent with the Medicare rules for coverage of this service. The services as billed were not otherwise consistent with the definition of the procedure code. The enrollee was not suspected of having a disorder of the neuromuscular junction. Additionally, the enrollee underwent an epidural steroid injection. This is not a service for which there is sufficient "risk" to the nervous system to warrant intraoperative neurophysiology monitoring. There were no associated services involved that were listed in the rules as covered indications for intraoperative neurophysiology monitoring services. Lastly, performance of electroencephalogram (EEG) during this type of surgery is not within the standard of care. Performance of EEG provides no clinical value/utility to the surgeon nor does it have any bearing on health outcomes. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing, intraoperative neurophysiology monitoring, and an electroencephalogram during coma or sleep have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937), intraoperative neurophysiology monitoring (95941), and an electroencephalogram during coma or sleep (95822) provided on November 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on
September 2, 2021.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you should not have a
coinsurance because you have financial assistance that should cover the cost. The Plan denied your request.
The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Part B drugs that are administered by a provider.
You have been asked to pay $279.71 which is 20% of the allowed amount for the Prolia injection. The allowed
amount is $1,398.54. ($1,398.54 x 20% = $279.71). The Prolia injection falls within the "Medicare Part B
prescription" 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 the Prolia injection
provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three extractions, erupted tooth requiring removal of
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided
September 22, 2021.
You asked the Plan to pay for the surgical tooth extractions. You say that you never got dental info which fully
explained your benefits. The Plan denied your request. The Plan says this service is not covered under your
benefits.
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 the three
extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of
mucoperiosteal flap if indicated (D7210) provided September 22, 2021.
Your complaint about potentially not receiving complete information about your dental benefits 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 office visit provided on June 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 office visit provided on June 3, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140) provided on August 18, 2021.

You asked the Plan to pay for the limited exam. You say that this service was medically necessary. The Plan denied your request. The Plan says this service was provided in a frequency that exceeds the limitations of your benefit.

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 can cover one limited exam to evaluate a problem (D0140) per plan year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the exam is requested in a frequency that is not covered under this benefit. Documentation shows that you had a previous limited oral exam in 2021, which was covered by the Plan at that time. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on
October 8, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment 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 there is no coinsurance, copayment, or deductible for an annual
wellness visit. If you receive services that address a medical condition during the same office visit, additional
cost-share may apply. You pay $10 for each covered visit or consultation in an outpatient location with your
primary care physician (PCP) or other primary care provider.
You have been asked to pay a $10 copayment for the office visit provided. On this day, your primary care
physician performed an annual wellness exam and a pacemaker evaluation. Your contract with the Plan says
that there is no coinsurance, copayment, or deductible for an annual wellness visit. However, if you receive
services that address a medical condition during the same office visit, additional cost-share may apply.
Enrollees pay $10 for each covered visit or consultation with your primary care physician or other primary care
provider. 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 office visit (99214) provided on October 8,
2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for codes 64721-59-RT and 64772-RT. We decided that the Plan does not have to pay for 64772-RT.

You asked the Plan to pay for codes 64721-59-RT and 64772-RT. You say that the billed services were medically necessary. The Plan says that these services are inclusive to other billed procedures.

We decided that the Plan has to pay for code 64721-59-RT. We also decided that the Plan does not have to pay for 64772-RT.

The Plan follows Medicare rules. The rules say that modifier -59 is used to indicate a distinct procedural service. This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury. 

We asked our coder 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 codes 64721-59-RT and 64772-RT. Our reviewer says that code 64772-RT is not supported for payment, but code 64721-59-RT is supported for payment. Our coder reviewer found code 64772-RT was not performed as postoperative pain management but was performed for documented chronic pain prior to surgery. Per Medicare, a separate payment for postoperative pain management is included in the primary procedure, unless treating preoperative chronic pain. Code 64721-59-RT has a distinct diagnosis from the fractures, as well as, the treatment provided, and therefore should be covered separately. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 64772-RT have not been met, but code 64721-59-RT is supported for payment. Therefore, we decided that the Plan has to pay for code 64721-59-RT and does not have to pay for code 64772-RT.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 30, 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 there is no network deficiency for these services and alternate network providers were found.

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 laboratory services provided to the enrollee on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 6, 2021 by an out-of-network (OON) provider.

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 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 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 office visit provided on July 6, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on September 21, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0483) provided on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 24, 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 72192 is a column II code to column I code 74178. 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 August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit (99214),
chemotherapy (96402), and the injection (J3315), provided on April 20, 2021.
You asked the Plan to waive the copayment for the specialist office visit, chemotherapy, and the injection. You
say that you should not have to pay anything. The Plan denied your request. The Plan says the cost share was
applied 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 20%
coinsurance for Medicare Part B prescription drugs and a $10 copayment for specialist visits.
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $10 copayment
for specialist visits. 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 specialist office visit
(99214), chemotherapy (96402), and the injection (J3315), provided on April 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99152) provided on November 14, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older".

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 use of code 99152 is not supported by the records provided. Our reviewer found that the procedure report does not include documentation of an independent trained observer. All criteria in a code description should be documented to confirm the procedure has been performed. Therefore, this procedure cannot be verified. 

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 the services (99152) provided on November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intermittent limb compression device
(E0676) provided on June 14, 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 item 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 10%
coinsurance for covered durable medical equipment and related supplies.

You have been asked to pay $425 ($4,250 x 10% coinsurance) for the durable medical equipment provided.
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 intermittent limb compression device
(E0676) provided on June 14, 2021.