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

 We decided that the Plan does not have to waive the copayment for the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete (76770) provided August 11, 2021.  

You asked the Plan to waive the copayment for the ultrasound. You say that you have been given mixed information about the cost of this service and are unhappy with the customer service provided by the Plan. The Plan denied your request. The Plan says the copayment was applied correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility.  You have been asked to pay a total of $104.84 for the ultrasound. The ultrasound falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 the ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete (76770) provided August 11, 2021.   

Your complaint about your experiences with poor customer service and plan website functionality 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.
We reviewed the file and the Medicare rules. We find that the criteria for coverage for the LDCT scan for lung
cancer have not been met. Specifically, the record indicates that the enrollee quit smoking 30 years ago
indicating that they are not a current smoker or former smoker who quit within the last 15 years. Therefore, we
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung
cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT code G0299) provided to the enrollee on June 25, 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 Medicare rules have not been met.  

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. As the claims were not initially billed under a UB-04 in order to establish the required HHA reports on the 0023 revenue code line the date of the first covered visit provided during the initial episode; we find that Medicare rule for payment of this claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT code G0299) provided to the enrollee on June 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient physical therapy (PT) services provided on August 3, 2020.  You asked the Plan to pay for the outpatient PT services provided on August 3, 2020. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was received beyond the 12 month timeframe.  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 the outpatient PT services provided from August 4, 2020, to August 31, 2020 was not filed until September 4, 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 the outpatient physical therapy (PT) services provided on August 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion/specialty drug administration (CPT code(s):
99601 and 99602) provided to the enrollee on January 14, 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. Per the 2021 National Physician Fee Schedule Relative Value File January
Release, HCPCS codes 99601 and 99602 are assigned a status code I = Not valid for Medicare purposes. As the
claim was billed with a CPT/HCPCS code which is invalid for usage with Medicare; we find that Medicare rule
for payment of this claim has not been met. If the provider determines that a billing error occurred during the
initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider
services for payment. Therefore, we decided that the Plan does not have to pay for home infusion/specialty
drug administration (CPT code(s): 99601 and 99602) provided to the enrollee on January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound debridement and complex repair provided on May 12, 2021.  

You asked the Plan to pay for the wound debridement and complex repair. You say that the provider is a certified surgical assistant, and the claim is denying incorrectly. The Plan denied your request. The Plan says the claim was coded incorrectly.    

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 13121, 13122, and 11043. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the wound debridement and complex repair have not been met. Therefore, we decided that the Plan does not have to pay for the wound debridement and complex repair provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided June 29, 2021.

You asked the Plan to pay for a pneumatic compression device and appliance. You say that the enrollee's physician had prescribed the use of a pneumatic compression device to prevent the formation of blood clots. The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) provided June 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 24, 2021.  You asked the Plan to waive the copayment for the emergency ambulance transport. You say that you remember being told that there would be no copayment for the ambulance service. The Plan denied your request. The Plan says the copayment was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground trip by ambulance.   The enrollee has been asked to pay a $250 copayment for the emergency ambulance transport. The emergency ambulance transport falls within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) provided June 24, 2021.   Your complaint about potentially being provided misinformation about cost-sharing for the service 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services.  You asked the Plan to pre-approve the services. 

You say that this is medically necessary. The Plan denied your request. The Plan says homemaking needs can be met with other services.    

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no current clinical records submitted for review. Therefore, there is no evidence that the enrollee is in need of home health skilled services. As such, associated home health services are not medically reasonable, reasonable, or coverable.  

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 pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the definitive drug testing provided on April 29, 2021.  

You asked the Plan to pay for the drug testing. You say that this testing is medically necessary. The Plan denied your request. The Plan says this was not billed with the correct POS code.    

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.  


We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on April 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021, to March 30, 2021.  You asked the Plan to pay for home health services. You say that a corrected claim has been submitted. The Plan denied your request. The Plan says the HIPPS code was not billed with the correct revenue code.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. The rules also say that a Health Insurance Prospective Payment System (HIPPS) code is valid only on claim lines with revenue code 0023.   We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, although a HIPPS code was billed on the claim, it was not billed on a claim line with revenue code 0023. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 2, 2021, to March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from August 25, 2021, to August 30, 2021.  

You asked the Plan to waive the copayment for the inpatient stay. You say that you feel you should not be required to pay this bill, as you were not in control of which facility provided treatment. You were taken to the closest hospital with an available bed and feel that these services should be covered in full because you qualify for the financial assistance program. The Plan denied your request. The Plan says these services are covered and were processed correctly according to your contract. You are responsible for a $100 copayment for each of the first seven days of an inpatient hospital stay. The Plan's financial assistance program does not apply in this case as the services were provided by a facility that does not participate in this program.  

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 $100 copayment for each of the first seven days of an inpatient stay.   

You have been asked to pay a $500 copayment for the five-day inpatient stay. 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 inpatient hospital admission and services provided from August 25, 2021, to August 30, 2021.   

Your complaint about the Plan's financial assistance program requirements and your lack of facility choice in this case 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.  

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for virus testing services received on August 22, 2021.  

You asked the Plan to pay for the services. You say that this should be covered as you had patients to see. The Plan denied your request. The Plan says you are contractually obligated to pay for coronavirus (COVID-19) testing when its screening for employment reasons.  

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, the services, 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 virus testing services received on August 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on June 24, 2021.  You asked the Plan to pay for bitewing x-rays. You say that you are requesting reconsideration because you had one previously in the year, but not as an oral evaluation. You also say you believe it should be covered again for the purpose of a routine evaluation. The Plan denied your request. The Plan says you have exceeded your maximum allowance for this service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers bitewing x-rays when the services are medically necessary and reasonable.   We looked at the file and Medicare rules. The records show you received a bitewing x-ray on January 21, 2021; therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of bitewing x-rays have not been met.    Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional x-ray (71045) provided on July 14, 2021.  

You asked the Plan to pay for an additional x-ray. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is not supported in the records.  

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.       

We find that an additional unit of CPT code 71045 is not supported in the medical record. The medical record only supports 1 unit of CPT code 71045, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of an additional x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an additional x-ray (71045) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound care services provided from March 2, 2021, through March 9, 2021, by an OON provider.  

You asked the Plan to pay for the OON wound care services. You say that the records were resubmitted and clearly show that these services were medically necessary. The Plan denied your request. The Plan says these services were not ordered by a network provider and are not emergent in nature. No authorization was requested to provide this care OON. As such, the denial is correct.  

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 wound care services provided from March 2, 2021, through March 9, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA)
(Kyphoplasty) (22513).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that your records show you do not have either an acute or subacute
vertebral compression fracture.

The Plan must follow Medicare rules. Medicare rules say that PVA can be covered if the Medicare 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 pre-approve these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. There is no
documentation that the facture is less than 12 weeks old. Our physician reviewer found that your condition
does not meet Medicare criteria for these services.

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 pre-approve Percutaneous Vertebral Augmentation (PVA) (Kyphoplasty) (22513).