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

We decided that the Plan does not have to pay for the office visit provided on March 31, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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. The records provided for review do not show that the service at issue was urgent or emergent.

Therefore, we decided that the Plan does not have to pay for the office visit provided on March 31, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging and surgical services rendered on August 16, 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 36140 is not supported and 75716 is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 36140 is introduction of needle or intracatheter, upper or lower extremity artery. 

We find that CPT code 36140 is not supported in the medical record. Specifically, there is no documentation of introduction of needle or intracatheter to an upper or lower extremity artery. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

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 75716 (bilateral extremity angiography) and 37227 (endovascular revascularization). Code 75716 is a column II code with a modifier indicator of 1 when billed with column I code 37227. Code 75716 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 imaging and surgical services rendered on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four two dimensional (2D) oral/facial photographic images (D0350 x4) provided on June 23, 2021.  

You asked the Plan to pay for the 2D oral/facial photographic images. You say that you would like to appeal this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.  

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 four two dimensional (2D) oral/facial photographic images (D0350 x4) provided on June 23, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).  

You asked the Plan to pre-approve TMS. You say that this is medically necessary because the enrollee has failed two medications. The Plan denied your request. The Plan says the requirements for coverage have not been met.  

The Plan must follow Medicare rules. Medicare rules say that transcranial magnetic stimulation (TMS) of the brain is considered medically necessary for use in an adult who meets one or more of the criteria listed in the rules section.  

We looked at the file and Medicare rules. The records do not show that the enrollee has had four trials of  psychopharmacologic agents. The records also do not show that the enrollee has previously had TMS or is a candidate for ECT. Based on this information, we decided that Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from August 13, 2021, to September 10, 2021.

You asked the Plan to waive the copayments for wound debridement. You say that you were not aware that you would owe anything for the services and discontinued once you found out. 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

You received wound debridement at an outpatient hospital facility from August 13, 2021, to September 10, 2021, for a total of 5 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $275 copayment per each visit. However, you are only being asked to pay $1,106.40, which is less than the total copayment amount. 

You have been asked to pay $1,106.40 for wound debridement. Wound debridement 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 copayments for wound debridement provided from August 13, 2021, to September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the required care needed cannot be received at a lower level of care. The Plan denied your request. The Plan says the member does not need to see a rehab doctor at least 3 times a week for evaluation of function and medical goals progress.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for tracheostomy because of maxillary alveolar squamous cell cancer. The enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 16, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the claim should be processed and paid and have received different answers as to why you 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 $25 copayment for specialist visits. 

You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the assistant surgeon services rendered on July 28, 2021.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  

The Plan must follow Medicare rules. The rules say that modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery. Modifier 80, 81 or 82 must also be billed when modifier AS is billed.  

We looked at the file and Medicare rules. The file shows that the services were not billed with the required -AS modifier. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the simple extraction (D7140) provided on October 5, 2021.  

You asked the Plan to pay for the extraction. You say that you had already reached the amount of money covered for dental benefits, but you had an emergency. The Plan denied your request. The Plan says the $1,000 benefit max was met before the processing of 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.     

Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the October 5, 2021, date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the simple extraction (D7140) provided on October 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chest computed tomography (CT) scan.

You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 CT scan. Our reviewer says that a CT scan is not medically reasonable and necessary in this case. Our physician reviewer found that on September 2, 2021, the enrollee had a CT scan of the chest which revealed slightly increased stranding, scar and/or atelectasis right lung base, but no signs of edema/pneumonia and no mention of a mass. He had reported no change in lung symptoms and was controlled on his medications for chronic obstructive pulmonary disease (COPD). Also, there was no report of the enrollee having a history of smoking or a prior history of lung cancer or lesions that require close monitoring. CT imaging was requested less than 6 months since the prior CT. Therefore, without sufficient support made for this request, the CT scan will be considered not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a chest computed tomography (CT) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay the in network rate for the core build up (D2950) and root canal (D3330) provided on August 24, 2021.  

You asked the Plan to pay the in network rate for the dental services. You say that you were advised by the dental office and customer service that this dentist was in network. The Plan denied your request. The Plan says the provider was out of network on the date of service in this case. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays.  

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  

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the provider in this case was out of network on the date of service in this case. Therefore, we decided that the Plan does not have to pay the in network rate for the core build up (D2950) and root canal (D3330) provided on August 24, 2021.   

Your complaint about being misled by a plan representative 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 reduce the copayment for a magnetic resonance imaging (MRI) provided by a network provider on October 8, 2021.  

You asked the Plan to reduce the copayment for the MRI. You say that you are appealing this $10 bill because you already paid a $175 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $185 copayment for each Medicare-covered MRI, CT, or PET scan.     

You have been asked to pay a $185 copayment for the MRI. The MRI 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 reduce the copayment for a magnetic resonance imaging (MRI) provided by a network provider on October 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for an ultrasound of the abdomen (76705) rendered on September 3, 2021.  

You asked the Plan to reduce the copayment for an ultrasound of the abdomen. You say that your portion should be just the $30 copayment you paid at the beginning of the liver ultrasound. The Plan denied your request. The Plan says you were charged the correct costs 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 $160 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic radiology services require specialized equipment beyond standard x-ray equipment and must be performed by specially trained or certified personnel. An example includes, but is not limited to ultrasounds.   

You have been asked to pay $92.61, which is less than the $160 copayment for an ultrasound of the abdomen. An ultrasound of the abdomen falls within the Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). The diagnostic radiology services require specialized equipment beyond standard x-ray equipment and must be performed by specially trained or certified personnel. An example includes, but is not limited to ultrasounds. benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for an ultrasound of the abdomen (76705) rendered on September 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a network provider
on August 16, 2021.

You asked the Plan to waive the copayment for the wound care. You say that you should not be responsible for
the copayment because the bed sore developed while you were under hospital care. The Plan denied your
request. The Plan says you have been asked to pay 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 Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges. For this date of service,
you have been asked to pay the allowed amount of the claim because this amount is less than the standard $260
copayment for the wound care.

You have been asked to pay a $179.08 copayment for the wound care. The wound care 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 wound care provided
by a network provider on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for Computed Tomography (CT) of the head or brain (70450) provided on September 28, 2021.  

You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70450 and 70496.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head or brain (70450) provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 3, 2021.  

You asked the Plan to pay for the prophylaxis. You say that you require dental prophylaxes every three months due to gum erosion. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.  

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, prophylaxis (D1110) is limited to two procedures per plan year. The record shows that you received prophylaxes (D1110) on January 12, 2021, and April 13, 2021 and your prophylaxis (D1110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lip biopsy (40490) provided on September 23, 2021 by a Medicare opt out provider.  

You asked the Plan to pay for the lip biopsy. You say that the doctor never told you he was non-participating until after you left the appointment. You also say that you feel in the past you have gone to this doctor and things were covered. The Plan denied your request. The Plan says this service was rendered by an opt out provider.    

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the lip biopsy (40490) provided on September 23, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided on October 15, 2020.  

You asked the Plan to pay for the hearing aids. You say that your plan covers hearing aids and there should be reimbursement for the cost. The Plan denied your request. The Plan says hearing aids must be purchased from the Plan's hearing aid vendor.  

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from the Plan's hearing aid vendor.   

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on October 15, 2020.