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

 We decided that the Plan does not have to pay for the chiropractic services coded 99211, G0283, 96372, 96372, and J3420 provided on March 17, 2021.  You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 99211, G0283, 96372, 96372, and J3420 are not supported in the medical record. Specifically, the submitted documentation supports one unit each of these codes, which were previously approved and paid by the Plan. There is no additional documentation supporting additional services were billed. Based on this information, we decided that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services coded 99211, G0283, 96372, 96372, and J3420 provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical procedures (D9215) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided June 28, 2021.  You asked the Plan to pay for the local anesthesia and diagnostic consultation. You say that you cannot afford the cost of the services. The Plan denied your request. The Plan says these services are 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 local anesthesia in conjunction with operative or surgical procedures (D9215) and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided June 28, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on August 29, 2021.  You asked the Plan to waive the copayment for emergency care. You say that your Plan was switched and now you owe high copayments and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $90 copayment for emergency care.   You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on August 29, 2021.  We note your complaint that you were switched to a new Plan with high copayments. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640 and 87798) provided to the enrollee on November 23, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640 and 87798, remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in Nursing in a Skilled Facility POS 31. Also, the laboratory results submitted indicate the specimen was collected on November 23, 2020, and received by the lab on November 24, 2020. Of note, the patient resides in New Jersey (NJ) and the billing laboratory is located in Texas (TX); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640 and 87798) provided to the enrollee on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing provided on August 18, 2021.  You asked the Plan to pay for the testing services. You say that the test can help predict the likelihood that cancer will be found by a biopsy. The Plan denied your request.   The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on August 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the direct skilled nursing services of a registered nurse (RN) (G0299) provided from February 1, 2021, to February 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the direct skilled nursing services of a RN. The Plan denied your request. The Plan says these services were rendered by a non-network provider and were not referred by a network provider. The Plan also says that these services were 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 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 direct skilled nursing services of a registered nurse (RN) (G0299) provided from February 1, 2021, to February 15, 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 basic metabolic panel services (CPT code(s): 82043, 80048, 80061, and 36415) provided to the enrollee on September 27, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 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 basic metabolic panel services (CPT code(s): 82043, 80048, 80061, and 36415) provided to the enrollee on September 27, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on April 7, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of the dialysis center.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.    We looked at the file and the rules. The records indicate the enrollee received services as part of treatment for ESRD. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services received from August 12, 2021 to September 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy services. You say that you feel you shouldn't have to pay anything. The Plan denied your request. The Plan says the services received 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 psychotherapy services received from August 12, 2021 to September 2, 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 molecular pharmacogenetic testing (CPT code 81230, 81240, 81241, and 81291) provided on November 4, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows that the enrollee had molecular pharmacogenetic testing on November 4, 2020. Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the molecular pharmacogenetic testing (CPT code 81230, 81240, 81241, and 81291) provided on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography, head; without contrast material(s) (CPT code 70544) provided to the enrollee on August 24, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Our records indicate a NCCI Procedure to Procedure (PTP) edit exists between 70551 and 70544. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography, head; without contrast material(s) (CPT code 70544) provided to the enrollee on August 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on August 11, 2021.

You asked the Plan to waive the copayment for the ambulance transportation services. You say that the services should be covered as you were assured there would be no copayment beforehand. 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 $275 copayment for Ambulance services.

You have been asked to pay a $275 copayment for ambulance transportation services. There is no record of any outreach to the plan to discuss the copayment beforehand. 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 provided on August 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient telehealth mental health services (99214, 99215, 99417) provided September 7, 2021 to September 14, 2021.  You asked the Plan to waive the copayment for the outpatient visits. You say that you need the services of your psychiatrist. You have been seeing her once a week, every week. $30 per visit is an extremely high amount of money and you would have to cut back on your psychological help. The Plan denied your request. The Plan says the claims were reprocessed with the correct copayment applied per the Evidence of Coverage.  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 $30 copayment for each telehealth outpatient mental health or outpatient psychiatric individual therapy visit.   You have been asked to pay $30 copayment for the outpatient visits. The outpatient visits falls within the Outpatient mental health care 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 outpatient telehealth mental health services (99214, 99215, 99417) provided September 7, 2021 to September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for IV tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on July 1, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. CPT code(s): S8301 and S1015 have a status code of I. Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Therefore, we decided that the Plan does not have to pay for IV tubing extension set (CPT code S1015) and infection control supplies (CPT code S8301) provided to the enrollee on July 1, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered. 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 $69.75 copayment for an emergency room visit, which is less than the $90 stated in the Plans contract. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a punch biopsy of the skin (11104) rendered on September 24, 2021.

You asked the Plan to waive the copayment for a punch biopsy of the skin. You say that it is ridiculous to pay this amount. You also say that you have tried calling the office as well and they will not answer. You also say that you are a senior and have difficulty paying this. The Plan denied your request. The Plan says you were 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 $275 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. 

You have been asked to pay a $275 copayment for a punch biopsy of the skin. A punch biopsy of the skin falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. 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 punch biopsy of the skin (11104) rendered on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 7, 2021.

You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis center.

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on September 1, 2021.

You asked the Plan to pay for the services provided. You say that the provider has been extremely helpful. The Plan denied your request. The Plan says the provider is not eligible to bill Medicare for services.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

We looked at the file and the rules. The file shows that services were provided by a licensed professional counselor. This type of provider is not eligible to participate in Medicare. 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 outpatient mental health services provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 9, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis center.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.     We looked at the file and the rules. The file shows that the enrollee received lab services as part of ESRD treatment. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services provided from December 24, 2020, to December 31, 2020.  You asked the Plan to pay for the services provided. You say that you were told your plan had acupuncture coverage. The Plan denied your request. The Plan says Medicare will not pay for acupuncture if you do not have chronic low back pain.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.    We looked at the file and Medicare rules. The records provided show that you were treated for numbness and coldness in your feet and hands. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from December 24, 2020, to December 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 27, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you had used up your Epinephrine injections, so you went to the nearest emergency facility because you had gotten stung in the mouth by a bee. You also say that you were given two Prednisone tablets and were discharged. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on September 27, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.