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

We decided that the Plan does not have to waive the deductible forphysician services provided by an out-of-network provider on December 22, 2020.You asked the Plan to waive the deductible forphysician services. You say that you do not agree with these charges.The Plan denied your request. The Plan says the correct deductible has been applied.Therules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for physician/practitioner services/out-of-network. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for physician/practitioner services/out-of-network. This cost sharing is a contractual obligation that had not been met at the time physician services was received on December 22, 2020.The total amount you are being asked to pay is $51.79. Therefore, we decided that the Plan does nothave to waive the deductible forphysician services provided by an out-of-network provider on December 22, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for coronavirus disease (Covid-19) testing (CPT code U0003)
provided to the enrollee on July 2, 2020.
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 enrollee's services should be billed under Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The
enrollee was enrolled in hospice from June 30, 2020, through April 25, 2021. Therefore, we decided that the
Plan does not have to pay for coronavirus disease (Covid-19) testing (CPT code U0003) provided to the
enrollee on July 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on December 16, 2020, by an
OON provider.
You asked the Plan to pay for home health services. You say that these services were provided in good faith.
You say it is the facility's responsibility to obtain prior authorization. The Plan denied your request. The Plan
says prior authorization was not obtained by the member's primary care physician.
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 home health services provided on December 16,
2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a hand finger orthosis provided on June 6, 2019, and September 10, 2019.
You asked the Plan to waive the coinsurance for a hand finger orthosis. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 20% coinsurance for DME and related supplies.
The allowed amount of the claim is $230.96, resulting in a coinsurance obligation of $92.38 ($46.19 x 2 visits = $92.38). You have been asked to pay a 20% coinsurance for each DME item. The hand finger orthosis 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 a hand finger orthosis (L3913) provided on June 6, 2019, and September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided October 23, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 80307, & G0483 are not supported in the medical record. Specifically, the place of service listed on the claim (POS 81, laboratory) does not match the place of service detailed in the records (POS 11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0483) provided October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan (93970) provided October 7, 2020.
You asked the Plan to pay for the duplex scan. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 93970 is not supported in the medical record. Specifically, the claim was billed without a valid diagnosis code for this CPT code. Based on this information, we decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for a duplex scan (93970) provided October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 18, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room (ER) services rendered on July 16, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the submitted records do not support the billing of code 99285.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers mustreport services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening physiologic function, including comprehensive history and physical examination, and medical decision-making of high complexity.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the submitted records do not support the billing of code 99285. Our physician reviewer found the emergency room visit does not support evaluation and management CPT 99285. The documentation supports a comprehensive exam with four system/body areas, and 10 organ systems, detailed examination with 11 system/body areas, and moderate level of medical decision making. The records support that there is a more appropriate evaluation and management code 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 pay forthe emergency room (ER) services rendered on July 16, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on September 12, 2020.You asked the Plan to pay forthe self-administered drugs taken in a hospital outpatient setting. You say that these drugs were essential and should have been properly billed. The Plan denied your request. The Plan says the self-administered drugs you received in the hospital emergency room are not covered under your Medicare Part B drug benefit The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does nothave to pay forthe self-administered drugs provided on September 12, 2020in a hospital outpatient setting.Benefits for the self-administered drugs taken in a hospital outpatient settingmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy and occupational therapy provided by a participating provider on October 22, 2020, to October 27, 2020.
You asked the Plan to waive the copayment for physical therapy and occupational therapy. You say that you were told that you would only be charged once. The Plan denied your request. The Plan says the correct copayments have been applied.
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 $10 copayment for outpatient rehabilitation services. You have been asked to pay a $10 copayment for each physical therapy and occupational therapy. The total amount you are being asked to pay is $30 ($10 (physical therapy 10/22/2020) + $10 (occupational therapy
10/22/2020) + $10 (physical therapy 10/27/2020) = $30). Physical therapy and occupational therapy fall within the outpatient rehabilitation services benefit category. The correct copayments have been applied to the services that were provided. 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 physical therapy and occupational therapy provided by a participating provider on October 22, 2020, to October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

e decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 19, 2020.You asked the Plan to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered.The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met.Therefore, we decided that the Plan does not have to pay forthe nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePneumovax-23 (90732).You asked the Plan to pre-approvePneumovax-23. You say that you believe this drug should be approved for coverage.The Plan denied your request. The Plan says the use of this drug requires the 23-Valent Pneumococcal Polysaccharide vaccine (Pneumovax-23) will be administered at least 1 year after the Pneumococcal 13-Valent Conjugate vaccine (Prevnar-13) has been given. The Plan also says that the enrollee does not meet the standards.The Plan must follow Medicare rules. Medicare rules say that an initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccination under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pneumovax-23 have not been met. The enrollee received Prevnar-13 on March 31, 2021, and an additional pneumococcal vaccine cannot be administered for 1 year after.Therefore, we decided that the Plan does not have to pre-approvePneumovax-23 (90732)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87631) provided on June 19,
2020.
You asked the Plan to pay for infectious agent detection. You say that this was medically necessary. The Plan
denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that testing billed with code 87631 may be billed in
places of service 20, 21, or 23 (Urgent care, Inpatient hospital, or Emergency room respectively) by a provider
of any medical specialty for whom the ordering of this test is within the provider's scope of practice and
institutional privileges. Outside of one of these places of service, these tests must be ordered by an infectious
disease specialist who is diagnosing and treating the beneficiary.
We looked at the file and Medicare rules. The testing at tissue was not billed in places of service 20, 21, or 23
and was not ordered by an infectious disease specialist. Based on this information, we decided that Medicare
rules for coverage of infectious agent detection have not been met. Therefore, we decided that the Plan does not
have to pay for infectious agent detection (87631) provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office or other outpatient visit (99213) provided on January 13, 2021, by an out of network (OON) provider.
You asked the Plan to pay for office or other outpatient visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 office or other outpatient visit (99213) provided on January 13, 2021, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided January 13, 2021.
You asked the Plan to pay for the periodontal exam. You say that the service is medically necessary for your long-term gum health. The Plan denied your request. The Plan says this service is not covered under your dental benefits.
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 comprehensive periodontal evaluation (D0180) provided January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical examination and evaluation, with initiation or continuation of diagnostic and treatment (CPT Code 92014), eyeglasses delux frames (CPT Code V2025), and lens sphere single plano 4.00 (V2100) provided on September 30, 2020, by an out-of-network provider.
You asked the Plan to pay for the vision services. You say that you were unable to see an in-network provider that could accommodate your wheelchair. The Plan denied your request. The Plan says the provider is outside of your network of providers and prior authorization was not obtained from the plan.
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 medical examination and evaluation, with initiation or continuation of diagnostic and treatment (CPT Code 92014), eyeglasses delux frames (CPT Code V2025), and lens sphere single plano 4.00 (V2100) provided on September 30, 2020, by an out-of-network provider.