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

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 12, 2019 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that the referring physician is a non-participating provider, and prior authorization was not 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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 12, 2019 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 18, 2020.

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 was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 18, 2020 by an out of network provider.

You asked the Plan to pay for the office visit with an out of network provider. You say that the service was medically necessary. The Plan denied your request. The Plan says you did not request 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 18, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on August 5, 2020.

You asked the Plan to pay for drug test. You say that you request that the Plan not penalize the lab because you are doing your part to provide timely testing and results during the COVID-19 pandemic. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is out-of-network.

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 physician services provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81226, 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81408) provided on September 25, 2020.

You asked the Plan to pay for genetic testing. You say that this testing was provided in good faith. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel. 

We find that CPT codes 81226, 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, and 81408 are not supported in the medical record. Specifically, these tests were performed in parallel and should be reported with a single code. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81226, 81230, 81231, 81232, 81240, 81241, 81283, 81328, 81335, 81408) provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 16, 2021.

You asked the Plan to pay for the office visit. You say that you have been partially reimbursed for the office visit in the past. You say that this provider helped diagnose you and you want to continue going to this provider for visits. The Plan denied your request. The Plan says you are obligated to pay for services rendered by providers that are not participating with Medicare.

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 office visit provided on March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on January 22, 2021.

You asked the Plan to waive the coinsurance for DME. You say that you disagree with how high the charges are. 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 20% coinsurance for DME and related supplies. 

You received DME on January 22, 2021. The total allowed amount is $467.13 and 20% of that is $93.43. 

You have been asked to pay the total coinsurance amount of $93.43 for DME. DME falls within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME provided on January 22, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for WATS3D testing provided on December 10, 2020.

You asked the Plan to pay for lab test. You say that this testing is not experimental/investigational in any way and testing was performed on the specimen obtained by the enrollee's treating physician. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is experimental/investigational.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that their decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for WATS3D testing provided on December 10, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) electrical stimulator supplies, 2 lead, per month (A4595) provided September 16, 2020.

You asked the Plan to pay for the neuromuscular stimulator and supplies. You say that please take into consideration and process the claim for further payment. The Plan denied your request. The Plan says evidence of misrepresented services.

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 code is not supported in the medical record. Specifically there is no evidence of an established relationship between the enrollee and the ordering physician, as required per Medicare guidelines and the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity . Based on this information, we decided that Medicare rules for coverage of the neuromuscular stimulator and supplies have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) electrical stimulator supplies, 2 lead, per month (A4595) provided September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the second pair of eyeglass frames (V2020) purchased on February 4, 2021.

You asked the Plan to pay for the eyeglass frames. You say that between the pandemic and issues with your own health in the last few years, this additional cost is a hardship. This was the first time you were able to get glasses in years, and request that the Plan cover them in full because you have not been able to use this benefit in recent years. The Plan denied your request. The Plan says that they have reimbursed the full $115 allowed by the contract. The remaining cost is your responsibility.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will pay up to $115 per year for non-Medicare covered eyewear. 

We looked at the file and the Plan's rules. The Plan has reimbursed you for the full $115 allowed by the contract. The remaining cost exceeds this allowance. Therefore, we decided that the Plan does not have to pay for the second pair of eyeglass frames (V2020) purchased on February 4, 2021.

Your complaint about what the Plan is able to cover under their supplemental benefits and whether or not additional provisions should be made due to the pandemic 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on December 26, 2020 to December 30, 2020.

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 J2260 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 J2260 is injection, milrinone lactate, 5 mg. 

We find that CPT code J2260 is not supported in the medical record. Specifically, the documentation shows that 125 mg of Milrinone was delivered, which does not support the number of units billed. 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 injection services rendered on December 26, 2020 to December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided December 11, 2020.

You asked the Plan to pay for the orthosis. You say that see attached medical documentation. Please see the copy of RX/medical necessity form with the supporting medical records. The Plan denied your request. The Plan says documentation indicates services are not necessary for treatment of the enrollee's condition.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on July 31, 2020.

You asked the Plan to reimburse you for the dental services. You say that the dental services D0220 and D0230 that you received were denied even though they were nearly identical to the services you received on a different date of services that were covered. You say that your coverage shows that there is a $0 copayment for x-rays. You also say that The Plan denied your request. The Plan says periapical x-rays are not listed as covered services.

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. Additionally, the record shows that you were not enrolled in the Dental Rider, which would have covered these services, on the date of service in this case. Therefore, we decided that the Plan does not have to reimburse you for the initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 14, 2020.
You asked the Plan to pay for the drug testing. 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. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 drug testing coded G0483 provided on May 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy (OT) services rendered on September 3, 2020.
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 97530 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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy (OT) services rendered on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on December 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 laboratory testing provided on December 18, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95822) provided on July 20, 2020.
You asked the Plan to pay for an electroencephalogram. You say that this was billed correctly. The Plan denied your request. The Plan says there is a more appropriate code for the service provided.
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 95822 is electroencephalogram (EEG); recording in coma or sleep only. We find that CPT code 95822 is not supported in the medical record. Specifically, the record does not show
that the recording was provided in a coma or a sleep study. Based on this information, we decided that Medicare rules for coverage of an electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95822) provided on July 20, 2020.