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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 

The Plan must follow Medicare rules. The rules say that Medicare pays for 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing and/or 
skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation 
services at a lower level of care.  Although further rehabilitation services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing facility. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 20, 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 procedure code 99203 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99203 is outpatient visit for evaluation and management
of new patient, including medically appropriate examination and low level of medical decision making, total
time 30-44 minutes.
We find that CPT code 99203 is not supported in the medical record. Specifically, the records show that the
enrollee was seen by this provider on November 25, 2020; therefore, a new office visit does not apply. Based
on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit rendered on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the podiatry visit you had on May 14, 
2021. 
 
You asked the Plan to reduce the copayment for the podiatry visit. You say that you think your copayment 
should only be $20. The Plan denied your request. The Plan says you were charged this copayment 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 $45 
copayment for visits with a podiatrist. 

You have been asked to pay a $45 copayment for the podiatry visit. 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 reduce the 
copayment for the podiatry visit you had on May 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (43239) 
provided on April 15, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that you were 
misinformed about the copayment for the procedure at issue. 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 $295 
copayment for Medicare-covered surgery or other services provided at an ambulatory surgical center or an 
outpatient hospital. 

You have been asked to pay a $224.33 copayment for an esophagogastroduodenoscopy. An 
esophagogastroduodenoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at 
Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have 
been asked to pay less than or equal to 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 esophagogastroduodenoscopy (43239) provided on April 
15, 2021.  
 
Your complaint about receiving erroneous or incomplete 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the magnetic resonance imaging (MRI) of
the spine you had at an outpatient hospital facility on August 4, 2021.

You asked the Plan to reduce the copayment for the MRI. You say that the copayment should have been $180,
not $275. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan
says that because the allowed amount for this service ($236.80) is less than your copayment obligation, you are
responsible for the full allowed 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 a $275
copayment for advanced imaging services in an outpatient hospital.

You have been asked to pay a $275 copayment for the MRI. The MRI falls within the advanced imaging
services in an outpatient hospital 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 reduce the copayment for
the magnetic resonance imaging (MRI) of the spine you had at an outpatient hospital facility on August 4,
2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit provided on June 8, 2019.
You asked the Plan to pay for emergency room visit. You say that this claim was originally filed within the
timely filing limit. The Plan denied your request. The Plan says the denial of payment for this claim is correct,
because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for emergency room visit was not filed until March 22, 2021. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for an emergency room visit provided on June 8, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the antigen therapy services rendered on August 13, 2020.
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 procedure code 95165 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 95165 is professional services for the supervision of
preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number
of doses).
We find that CPT code 95165 is not supported in the medical record. Specifically, there is no documentation of
professional services for the supervision of preparation and provision of antigens for allergen immunotherapy.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the antigen therapy services rendered on August
13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam provided by an out-of-network provider
on March 25, 2021.
You asked the Plan to pay for the routine eye exam. You say that the provider advised they accepted your plan
insurance, and no exam fee was due at the time of service. The Plan denied your request. The Plan says out-of-network
services 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 provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of a routine eye exam have not been met. Specifically, the routine eye exam was received from an
out-of- network provider. Therefore, we decided that the Plan does not have to pay for the routine eye exam
provided by an out-of-network provider on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on April 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 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 an office visit (99204) provided on April 23, 2021, by an out-of-network (OON) provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician or allowed practitioner certification for 
Medicare-covered home health services under a home health plan of care (G0180) provided on December 4, 
2020. 
 
You asked the Plan to pay for the home health service. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. 

The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 2, 2020. The service in question was provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the physician or 
allowed practitioner certification for Medicare-covered home health services under a home health plan of care 
(G0180) provided on December 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on
January 16, 2021.

You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on January 16,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right radiofrequency ablation (RFA) of the sacroiliac
(SI) joint nerves.
You asked the Plan to pre-approve the RFA of the SI joint. You say that it is felt that this would be beneficial
given that the diagnostic block provided 70% pain relief. The Plan denied your request. The Plan says RFA of
the SI joint nerves is not supported and is considered experimental at this time.
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 pre-approve the RFA of the SI joint. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered
experimental and investigational. Studies completed say that this procedure does not improve outcomes
compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed
using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 RFA of the SI joint have not been met. Therefore, we decided that the Plan
does not have to pre-approve right radiofrequency ablation (RFA) of the sacroiliac (SI) joint nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device, pneumatic compression device (PCD), and multivitamin injections rendered on December 2, 2020. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy is covered for chronic low back 
pain when part of an approved clinical study. The rules say that PCDs are covered for the treatment of 
lymphedema. The rules say that Vitamin B12 injections are not medically necessary. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received TENS therapy, PCD 
therapy, and a Vitamin B complex nutria-pharmaceutical blend injection for the treatment of bilateral lower 
extremity pain. These services are not covered for this indication. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the transcutaneous electrical nerve stimulation (TENS) device, pneumatic compression device 
(PCD), and multivitamin injections rendered on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services represented by code 98941 provided from October 6, 2020 to November 12, 2020.
You asked the Plan to pay for code 98941. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 98941.
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 98941 is Chiropractic manipulative treatment (CMT); spinal, 3-4 regions. We find that CPT code 98941 is not supported in the medical record. Specifically, the submitted medical
records do not indicate that Chiropractic manipulative treatment (CMT); spinal, 3-4 regions was performed on these dates of service. Based on this information, we decided that Medicare rules for coverage of code 98941 have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services represented by code 98941 provided from October 6, 2020 to November 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services provided on May 4, 2021.
You asked the Plan to waive the copayment for the physical therapy services. You say that the therapist was not able to complete the appointment due to extreme post-surgical pain and lack of movement. You say that there was no service or physical therapy provided and you do not intend to pay the $40. The Plan denied your request. The Plan says the copayment 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 $40 copayment at an in-network provider.
You have been asked to pay a $40 copayment for the physical therapy services. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show the physical therapist reviewed your medical history, current condition and performed a physical therapy evaluation. 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 physical therapy services provided on May 4, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for colorectal cancer screening (G0121) provided June 15, 2021.
You asked the Plan to pay for colorectal cancer screening. You say that you were not told that this provider was out of network and that the deductible would be higher. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 out of network deductible which applies to Colorectal cancer screening. The item or service you asked the Plan to pay for falls within the benefit category Colorectal cancer screening. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 out of network deductible which applies to Colorectal cancer screening. This cost sharing is a contractual obligation that had not been met at the time colorectal cancer screening was received on June 15, 2021. Therefore, we decided that the Plan does not have to pay for colorectal cancer screening (G0121) provided June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the spring powered device for lancet rendered on December 8, 2020.

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 covered.

The Plan must follow Medicare rules. The rules say that more than one spring powered device (code A4258) per 6 months is not reasonable and necessary. 

We looked at the file and Medicare rules. The file shows that the enrollee previously received a spring powered device for lancet described by code A4258 on July 1, 2020 that was approved by the Plan. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the spring powered device for lancet rendered on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 28, 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 99215 (office visit) and 99220 (initial observation care). Code 99215 is a column II code with a modifier indicator of 1 when billed with column I code 99220. Code 99215 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 June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99204) and the ophthalmic biometry (92136) provided on July 28, 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 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 $35 copayment for an office visit to a specialist. 

You have been asked to pay a $35 copayment for the specialist office visit 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 copayment for the office visit (99204) and the ophthalmic biometry (92136) provided on July 28, 2021.