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

We decided that the Plan does not have to reduce the copayments for the specialist office visits, the diagnostic tests, and the x-ray provided on March 1, 2021 and March 26, 2021. You asked the Plan to reduce the copayments for the specialist office visits, the diagnostic tests, and the x-ray. You say that you are being charged incorrect copayment amounts for your services. The Plan denied your request. The Plan says the specialist copayment amount on March 26, 2021 has been reprocessed to reflect the correct cost sharing amount. The Plan says you have been asked to pay the correct cost-sharing amount for the remaining services.
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 $30 copayment for in-network physician specialist services, a $75 copayment for in-network diagnostic procedures and tests, and a $10 copayment for in-network x-rays. You have been asked to pay a total of $115 for the specialist office visits, the diagnostic tests, and the x-ray. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The diagnostic tests and the x-ray fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the uroflowmetry and the ultrasound capacity test are considered diagnostic tests. The record also shows the single highest copayment for services on March 1, 2021 is $75. See chart below.
Dates of Service
Service
Allowed Amount
Copayment
Member Liability
March 1, 2021
Specialist office visit
$110.07
$30
$51.51
March 1, 2021
Uroflowmetry
$13.85
$75
$13.85
March 1, 2021
Ultrasound urine capacity test
$9.64
$75
$9.64
March 26, 2021
Specialist office visit
$126.87
$30
$30
March 26, 2021
X-ray
$38.26
$10
$10
Total
$115
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 copayments for the specialist office visits, the diagnostic tests, and the x-ray provided on March 1, 2021 and March 26, 2021.
Your complaint about the Plan's poor service regarding the errors on the Explanations of Benefit 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 additional physical therapy (PT) services to be provided in the home health setting.
You asked the Plan to pre-approve home health services. You say that it is felt that ongoing PT is needed. The Plan denied your request. The Plan says continued PT services are not required.
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 home health services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found the enrollee does not have documented ongoing skilled PT needs. The enrollee is ambulating household distances. The enrollee has a caregiver to supervise and assist him. As such, ongoing PT is not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) services to be provided in the home health setting.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgery provided on May 6, 2021.
You asked the Plan to waive the deductible for the outpatient surgery. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The Plan says the correct amount has applied towards your deductible per your contract with the Plan.
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 $750 deductible that must be met before the Plan will pay their share for Outpatient surgery. You have been asked to pay $224.60 towards your deductible for the outpatient surgery. The outpatient surgery falls within the Outpatient surgery 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 deductible for the outpatient surgery provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided March 2, 2021.
You asked the Plan to pay for the continuous glucose monitor. You say that the CGM was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery. The records did not show and itemized delivery ticket. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97032-GP, 97112-GP, 97139-GP, 97032-GP), compounded drugs (J3490-KP, J3490-KQ, J3490-59, J3411, J3415), drug administration (96372), and an office visit (99212-25) provided on January 25, 2021. You asked the Plan to pay for physical therapy services, compounded drugs, drug administration, and an office visit. You say that these services were denied in error. The Plan denied your request. The Plan says these services are not supported.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. We looked at the file and Medicare rules. The records show that the physical therapy services at issue were not provided by a provider that has a physical therapy license in the state that the services were performed in. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Finally, the office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. Based on this information, we decided that Medicare rules for coverage of physical therapy services, compounded drugs, drug administration, and an office visit have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97032-GP, 97112-GP, 97139-GP, 97032-GP), compounded drugs (J3490-KP, J3490-KQ, J3490-59, J3411, J3415), drug administration (96372), and an office visit (99212-25) provided on January 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 22 physical therapy (PT) visits.
You asked the Plan to pre-approve 22 PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 22 PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 22 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 22 physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 13, 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 00790 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 00790 is anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified. We find that CPT code 00790 is not supported in the medical record. Specifically, there is no documentation that anesthesia for an intraperitoneal procedure was performed. 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 anesthesia services rendered on November 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit (99214) and the telehealth facility fee (Q3014) rendered by the out-of-network (OON) provider on January 19, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that 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 Plan contract says that the Plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The provider in this case is not a network provider with the Plan. The Plan issued their denial as the services were rendered by an out of network provider, without prior authorization. However, the Plan contract states that enrollees can receive services from out of network providers, as long as the services are covered benefits that are medically necessary. Additionally, the Plan contract states that members are not required to obtain prior authorization or a referral as a condition for covering their services provided. Therefore, we decided that the Plan has to pay for the office visit (99214) and the telehealth facility fee (Q3014) rendered by the out-of-network (OON) provider on January 19, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on October 29, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the submitted medical records do not support the units 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 the denied codes is: HCPCS J1955: Injection, levocarnitine, per 1 gm HCPCS J3411: Injection, thiamine hcl, 100 mg HCPCS J3415: Injection, pyridoxine hcl, 100 mg HCPCS J3490: Unclassified drugs We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the medical records provided indicate that nutria-pharmaceutical blend was administered, which does not allow for each separate component of the blend to be billed, and only allows for one unit of service to be billed. There is a more appropriate HCPCS code to use for billing this service. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on October 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 9, 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, a cardiovascular risk assessment panel, 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 February 9, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the periodic comprehensive preventive medicine reevaluation (99397) provided on April 7, 2021.
You asked the Plan to pay for code 99397. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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 follows these rules. You were referred for code 99397 by a contract provider. The file does not show that the Plan provided notice that code 99397 would not be covered. Under Medicare rules, this means code 99397 is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the periodic comprehensive preventive medicine reevaluation (99397) provided on April 7, 2021.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic physical therapy services.
You asked the Plan to pre-approve the aquatic physical therapy. You say that you feel that this is medically needed. The Plan denied your request. The Plan says criteria for this service are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 aquatic physical therapy.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the patient has had prior therapy and the documentation does not reveal objective outcome of this therapy, or a detailed neuromuscular exam noting functional deficits that demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The documentation does not reveal that the patient requires aquatic therapy over land-based therapy. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 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 aquatic physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve auricular nerve stimulation.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the requested services are a form of acupuncture. The services are not being requested to treat chronic low back pain. Therefore, we decided that the Plan does not
have to pre-approve auricular nerve stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a contrast injection (A9579) provided November 23, 2020.
You asked the Plan to pay for the injection. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed 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 A9579 is not supported in the medical record. Specifically, there is a more appropriate
CPT code that describes the services at issue (A9577). Based on this informat ion, we decided that Medicare
rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay
for a contrast injection (A9579) provided November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the 2 crowns (D2740) for teeth # 24 and 25 provided on March 15, 2021.
You asked the Plan to pay for the dental services. You say that you needed all of your bottom teeth fixed. You say that you do not understand why 4 of the 6 crowns were covered. You also say that you feel that the other 2 crowns should be covered too. The Plan denied your request. The Plan says that the provider in this case is out of network. The Plan also says that dental services performed out of network are not covered.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The services in this case were denied based on the provider's status with the Plan. The Plan's website clearly indicates that the provider in this case is in network. Additionally, the record shows that the Plan paid for 4 crowns that you received on the same date of service. Therefore, we decided that the Plan has to pay for the 2 crowns (D2740) for teeth # 24 and 25 provided on March 15, 2021.
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.