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

 We decided that the Plan does not have to pay for the chest x-ray rendered on September 15, 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 71045 (chest x-ray, single view) and 71110 (bilateral rib x-ray, three views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71110. Code 71045 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 chest x-ray rendered on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for dialysis treatments provided from August 3, 2021, to August 31, 2021.  You asked the Plan to waive the coinsurance for the dialysis treatments. You say that you cannot afford the copayments as you are on a limited income. 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 a 20% coinsurance for dialysis services within the service area.   The file shows you had 17 dialysis treatments from August 3, 2021, to August 31, 2021. You have been asked to pay $65 for each treatment, which is 20% of the allowed amount ($325 allowed amount x 20% coinsurance = $65). The total for all 17 treatments is $1105 ($65 coinsurance x 17 treatments = $1105). The dialysis treatments fall within the Services to Treat Kidney Disease 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 dialysis treatments provided from August 3, 2021, to August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on April 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is a non-participating provider, and the referring provider is a non-participating provider. The Plan also says that prior authorization was not obtained by the provider or facility.  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 drug testing (G0483) provided on April 29, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the partial upper denture (D5213) provided on July 22, 2021 by an out of network dentist.  You asked the Plan to pay an additional amount for the partial denture. You say that you have done everything by the book. You say that you have $2,000 for dental. You say that this should have been applied to this service. You also say that you have paid $1,250 toward this bill. The Plan denied your request. The Plan says the claim was processed correctly.  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 and partial denture is listed as covered, there is a 75% coinsurance that applies when you receive this service out of network. Additionally, out of network dentists may bill you for any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to pay an additional amount for the partial upper denture (D5213) provided on July 22, 2021 by an out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the crown (D2740) provided on July 22, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay more for the crown. The Plan denied your request. The Plan says this service was rendered by an OON provider.  

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, you are responsible for a 50% coinsurance of the covered Plan allowance for the crown, plus the difference between the billed amount and allowed amount when the service is received OON. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on July 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advanced care planning provided on January 19, 2021.  

You asked the Plan to pay for the services provided. You say that the provider spent necessary time with the enrollee. The Plan denied your request. The Plan says no modifiers are allowed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

The file shows that CPT code 99497 was billed with code 99291. This code pair has a modifier indicator of 0. We find that CPT code 99497 is not eligible for payment when billed with this code pair.  Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the advanced care planning provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the endoscopy provided on July 23, 2021.  You asked the Plan to waive the copayment for the endoscopy. You say that you pay monthly for insurance and barely use it. You say that you continue to work because you have very little income and cannot afford this. 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 $200 copayment per visit at ambulatory surgical centers.     You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the health club membership for the 2020 Plan year.  You asked the Plan to pay for the health club membership. You say that you had a lot of continuing health issues and should be reimbursed. The Plan denied your request. The Plan says you missed the plan time frame to receive reimbursement toward your 2020 Wellness Allowance.  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $150 of gym benefits when the reimbursement request is received no later than March 31st of the following year.  The Plan's rules for coverage of gym benefits have not been met because the reimbursement request was not received by March 31, 2021. Therefore, we decided that the Plan does not have to pay for the health club membership for the 2020 Plan year.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97112, 97016, G0283, J3411, J3415, J3490, and J7999) provided on August 3, 2021.  You asked the Plan to pay for the Sanexas device and vitamin injections. The Plan denied your request. The Plan says Medicare does not cover Prolotherapy.    The Plan must follow Medicare rules. Medicare rules state that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage. The rules also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas device and vitamin injections have not been met. Payment for Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes 96372 and J3411, J3415, J3490, and J7999 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Additionally, review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP who is not licensed to provide physical therapy in the State. Therefore, we decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97112, 97016, G0283, J3411, J3415, J3490, and J7999) provided on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (20924-59, 26035-59 and 26145-59) provided to the enrollee on March 30, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found for code 20924 the Operative report documents "The flexor carpi radialis was now harvested from the forearm through a transverse incision at the muculotendinous junction. Tenotomy was performed minimizing muscle trauma.  Freer elevator was passed volar and dorsal to tendon to facilitate its mobilization.  The tendon was then withdrawn from the distal incision out of the forearm leaving it attached to the second metacrpal base".  Operative report supports a tendon graft was performed, however this would be inclusive to the primary procedure.  For code 26035 the Operative report documents "The overlying fascia was divided from proximal to distal decompressing the nerve through the cubital tunnel well into the flexor carpi ulnaris muscle".  The criterion for reporting this procedure is not documented in the operative report.  To report a procedure code, all of the criteria that is in the description of the code must be documented to confirm the procedure has been performed.  The operative report does not document injection injury.  For code 26145 the Operative report documents "Local flexor ten synovectomy was performed on the flexor digitorum superficialis and profundus tendons within the confines allowed by the incision".  Documentation does not support a radical excision with documentation of the separate pathologic process and clinical indications supporting the radical tenosynvectomy, Per NCCI Policy Manual.  We looked at this coder's review, the file, and Medicare rules. 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 physician services (20924-59, 26035-59 and 26145-59) provided to the enrollee on  March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 26, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this should be reported with CPT 81479.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient post-stabilization services provided after 10:00 AM on July 12, 2021, to July 14, 2021.  You asked the Plan to pay for the inpatient post-stabilization services. You say that the enrollee required the services that were provided. You also say that you would like this decision to be reconsidered. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 10:00 am on July 12, 2021 and subsequent post stabilization care was not approved in compliance with the health plan's authorization procedures. The Plan also says that all emergent care up to the point of stability has been paid for.  The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.   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 inpatient post-stabilization services. Our reviewer says that post stabilization care services at the non-Plan facility were not medically necessary or reasonable. Our physician reviewer found the review indicates that all inpatient care provided after 10:00 AM on July 12, 2021, to 9:00 PM on July 14, 2021 was not needed on an emergent basis. Our reviewer found that the enrollee as of this time was hemodynamically and neurologically stable for ambulance transport with monitoring to a Plan facility. Our physician reviewer also found that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.  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 inpatient post-stabilization services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient post-stabilization services provided after 10:00 AM on July 12, 2021, to July 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on  August 20, 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 must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations.  

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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is requesting reimbursement for outpatient behavioral health services CPT 90837 for services rendered on August 20, 2021 for the treatment of Major Depressive Disorder Single Episode, Unspecified. Based on a review of the records provided, there is no documentation of the enrollee having obtained a prior consult by an attending or primary care physician for the treatment. Therefore, the required documentation was not present. There is no documentation of a consult or response to a consult. The provider did not provide adequate documentation to meet medical necessity criteria for the treatment of this patient for her mental health disorder.  

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 pay for psychotherapy services provided to the enrollee on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on August 27, 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 (99214) provided on August 27, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a diagnostic mammography provided on February 22, 2021.  

You asked the Plan to waive the copayment for the mammogram. You say that the provider informed you that the procedure would be covered in full. The Plan denied your request. The Plan says you have been charged 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 a $75 copayment for diagnostic procedures and tests.   

You have been asked to pay a $75 copayment for the mammogram. Please note that the procedure is considered diagnostic due to your cancer history. The mammogram 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 a diagnostic mammography provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on July 14, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for an office visit. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is a non-participating provider and there is no referring provider involved in these services. The Plan also says they did not authorize any services for this provider.  

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 (99213) provided on July 14, 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 surgical pathology services coded 88305 and the special stain including interpretation and report coded 88312 provided on April 22, 2021.  

You asked the Plan to pay for the surgical pathology services and the special stain including interpretation and report. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT codes 88305 and 88312 are not supported in the medical record. Specifically, these codes have a professional component/technical component (PC/TC) indicator of 1. CPT codes 88305 and 88312 were billed and paid on the facility claim and per guidelines payment is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services and the special stain including interpretation and report have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 and the special stain including interpretation and report coded 88312 provided on April 22, 2021.