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

 We decided that the Plan does not have to pay for laboratory services provided on June 22, 2021.  You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on May 13, 2021, by an 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 May 13, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope provided on June 1, 2021.  You asked the Plan to waive the copayment for the biopsy. 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 $260 copayment for surgery provided at an ambulatory surgical center.      The service you received is considered a surgical service. You have been asked to pay a $260 copayment for the biopsy. The biopsy 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 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 biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope provided on June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 20, 2020.  You asked the Plan to pay for the services provided. You say that you do not personally see patients. The Plan denied your request. The Plan says the billed codes 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 code. We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records provided do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for testing services provided to the enrollee on November 17, 2020.  You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is:  CPT 51729:  Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique  CPT 51741:  Complex uroflowmetry (eg, calibrated electronic equipment)  CPT 51784:  Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique  CPT 51797:  Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure)  We find that CPT code  is not supported in the medical record. Specifically, the records indicate that the services were actually performed on November 16, 2020. The services cannot be verified for the billed date of service. Based on this information, we decided that Medicare rules for coverage of  have not been met. Therefore, we decided that the Plan does not have to pay for testing services provided to the enrollee on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 2, 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 testing is not covered.  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 solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a prefabricated stainless-steel crown (D2391) provided by a participating provider on July 26, 2021.  You asked the Plan to pay for a prefabricated stainless-steel crown. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D2931 is not a covered 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.  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 a prefabricated stainless-steel crown (D2391) provided by a participating provider on July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.

You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested power wheelchair and accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power wheelchair and accessories.

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 a power wheelchair and accessories. Our reviewer says that the enrollee does not meet criteria for the requested power wheelchair and accessories. Our physician reviewer found the documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of daily living (MRADLs) in the home. The documentation indicates the enrollee has 24 hours support therefore it is not clear why the enrollee's mobility deficit is unable to be helped with a manual wheelchair. Additionally, the requested Group 2 power wheelchair with power tilt exceeds the enrollee's medical needs. There is no evidence that the enrollee is at high risk for development of a pressure ulcer, or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a fine needle aspiration biopsy provided on July 20, 2021.  You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you received the same procedure in the past and did not owe a copayment. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You received a fine needle aspiration biopsy at an outpatient hospital facility on July 20, 2021. A fine needle aspiration biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment.  You have been asked to pay a $325 copayment for a fine needle aspiration biopsy. A fine needle aspiration biopsy 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 a fine needle aspiration biopsy provided on July 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from July 22, 2021, through July 23, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you couldn't be admitted to the hospital due to capacity issues and your family was not allowed to bring any of your home medications. The Plan denied your request. The Plan says self-administered drugs are not covered by Part B.   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 from July 22, 2021, through July 23, 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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81479) provided on February 1, 2020.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-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 services at issue in this appeal.  The Plan did not pre-approve the service at issue.    We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided on February 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on June 8, 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 29823 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).  We find that CPT code 29823 is not supported in the medical record. Specifically, there is no documentation of surgical shoulder arthroscopy with extensive debridement of three or more discrete structures. 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 surgical services rendered on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the podiatry visit you had on January 8, 2021.  You asked the Plan to waive the copayment for the podiatry visit. You say that this was a routine diabetic visit, so there should be no copayment. The Plan denied your request. The Plan says this was not a routine visit despite your diagnosis of diabetes.  Because this wasn't a routine visit, the normal podiatry copayment applies.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for podiatry visits.   We looked at the records from this visit.  While you did receive some services related to diabetic foot care, you were also evaluated for a contusion and discolored nail on your right big toe after dropping a box on it.  This part of the evaluation is not part of a routine visit, and that is why the normal podiatry copayment applies. You have been asked to pay a $40 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 waive the copayment for the podiatry visit you had on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on March 30, 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 were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when specific criteria are met.  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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of recurrent major depressive disorder and unspecified anxiety disorder. The documentation consists of an unsigned GeneSight Order Medical Necessity Documentation form and the results of the testing. There are no clinical medical records available for review. The documentation does not support that the coverage criteria for GeneSight Psychotropic Assay testing were met in this case.  The documentation does not support that GeneSight Psychotropic Assay testing was medically reasonable and necessary for the enrollee.  We looked at this physician'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 the GeneSight Psychotropic Assay rendered on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray provided on July 27, 2020.  You asked the Plan to pay for the x-ray services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 was billed with code 36573. CPT code 71045 may be eligible for payment when billed with this code pair. The claim provided does not indicate CPT code 71045 was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on July 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on August 8, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you were told by the hospital that you needed to be transferred to another hospital because there was no room for you.  You said that you were told that there would be no charge to transport you. 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 $250 copayment for ambulance services.     You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless of the reason for the 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 services you received on August 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray 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 the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. The file supports one unit of the code, which has been paid 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 hip x-ray rendered on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 14, 2021.

You asked the Plan to pay for the CT scan. You say that the service was billed with an appropriate modifier. The Plan denied your request. The Plan says criteria for modifier 59 have not been met.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

In this case, the CPT Code Manual definition of code 72192 is computed tomography, pelvis, without contrast material. We find that code 72192 was billed with the -59 modifier. The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the CT scan at issue was performed during the same session/encounter as the CT scan of the abdomen and pelvis.

Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the colonoscopy services (45385) provided on June 30, 2021.  You asked the Plan to pay for the colonoscopy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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.  In this case, the CPT Code Manual definition of code 45385 is colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.   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 colonoscopy services. Our reviewer says that CPT code 45385 does not meet criteria for billing or reimbursement consideration.   Our reviewer found the documentation does not describe removal of tumor, polyp or other lesion by snare technique, and therefore cannot be confirmed.  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 colonoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy services (45385) provided on June 30, 2021.