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

 We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy (45380) provided on June 17, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 there is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. If the screening test results in a biopsy or removal of a lesion or growth, the procedure is considered diagnostic, and the outpatient surgery cost sharing may apply. Enrollees must pay a $300 copayment per visit, per provider, per day for surgery performed in an in-network outpatient hospital setting.  You have been asked to pay a $300 copayment for the Medicare-covered surgery provided in an in-network outpatient hospital setting. The medical record indicates that a colorectal screening exam was performed, and colonic polyps were found and removed for biopsy. The Plan contact states that if a screening test results in a biopsy or removal of a lesion or growth, that procedure is considered as diagnostic, and an outpatient surgery copayment may apply. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy (45380) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and re-cement or re-bond fixed partial denture (D6930) provided October 12, 2021, by an out-of-network (OON) dentist.  You asked the Plan to pay for the intraoral x-rays and re-cement or re-bond of fixed partial denture. You say that the dental office did not inform you that they are now out-of-network. The Plan denied your request. The Plan says these services are not covered because they were provided OON.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the oral exam, intraoral x-rays and re-cement or re-bond of fixed partial denture when the services are provided by a participating dentist.  We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the oral exam, intraoral x-rays and re-cement or re-bond of fixed partial denture have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and re-cement or re-bond fixed partial denture (D6930) provided October 12, 2021, by an out-of-network (OON) dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) and therapeutic injections/procedures (97750, 96372, 97112, J3411, J3415, J7999, 97016) provided August 2, 2021.  You asked the Plan to pay for electrical stimulation and therapeutic injections/procedures. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were incorrectly billed.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services by an NP or 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.  We looked at the file and Medicare rules. Based on a review of the file and publicly available records, we find that the physical therapy services at issue were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. 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 payable as billed, the drug administration code, 96372, also cannot be paid. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes. Based on this information, we decided that Medicare rules for coverage of electrical stimulation and therapeutic injections/procedures have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) and therapeutic injections/procedures (97750, 96372, 97112, J3411, J3415, J7999, 97016) provided August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography (51785 and 95870) provided on April 7, 2021.  You asked the Plan to pay for the needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted 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.  In this case, the CPT Code Manual definition of code 51785 is needle electromyography studies (EMG) of anal or urethral sphincter, any technique.  The CPT Code Manual definition of code 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters.  We asked our coder 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 needle electromyography. Our reviewer says that CPT code 51785 does not meet criteria for billing or reimbursement consideration. The Intraoperative Neuromonitoring report does not clearly document electrodes or needle inserted in the rectum, and muscles recorded. In this case, this procedure cannot be verified as performed. Our reviewer found CPT code 95870 does not meet criteria for billing or reimbursement consideration. The Intraoperative Neuromonitoring report does not clearly document this procedure as an independent procedure, therefore modifier 59 cannot be verified. For use of modifier 59 distinct procedural service would be reported to identify procedures and services that are not normally reported together.  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 needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (51785 and 95870) provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive hearing test (92557) provided on October 14, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the comprehensive hearing test. You say that you would like reconsideration for payment of the denied claim. The Plan denied your request. The Plan says a referral from your primary care physician is required.  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 comprehensive hearing test (92557) provided on October 14, 2020 by an out-of-network (OON) provider.
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 inpatient rehabilitation is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.  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 based on the enrollee's medical stability, they do not need physician supervision three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs are noted in the record. At the current functional level,  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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation services and inpatient hospital services rendered from January 26, 2021, to January 29, 2021.  You asked the Plan to waive the copayment for the ambulance transportation services and inpatient hospital services. You say that the services should be covered. The Plan denied your request. The Plan says the cost sharing applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for Ambulance services (one way) and a $200 copayment per day of Inpatient hospital care.  The enrollee has been asked to pay a $200 copayment for the ambulance transportation services and a $400 copayment for two days of inpatient hospital services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation services and inpatient hospital services rendered from January 26, 2021, to January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve abdominoplasty for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a grade 1 pannus, and desires to improve the appearance of the abdomen. The record does not indicate that the enrollee has complicating factors refractory to standard medical therapy. The elements of the coverage criteria are not satisfied.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve abdominoplasty for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on August 4, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the enrollee did not come to the lab which means they did not use their out-of-network benefits. You say the participating doctor sent the specimen. 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 record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on August 4, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the reline of a mandibular partial denture (D5741) and mandibular partial denture (D5212) provided on March 15, 2021, and June 7, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the reline of a mandibular partial denture and mandibular partial denture. You say that you say that you were told 25% and 50% of these services would be covered. You also say that you would like at least 25% of these services covered by the Plan. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, you are responsible for a 75% coinsurance of the allowed amounts for both the reline of a mandibular partial denture (D5741) and mandibular partial denture (D5212), plus the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the reline of a mandibular partial denture (D5741) and mandibular partial denture (D5212) provided on March 15, 2021, and June 7, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on March 26, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you had Medicaid at this time and should not owe anything. 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 Medicare Part B prescription drugs. 

You received Medicare Part B drugs on March 26, 2020. The record shows that you had not had Medicaid at the time services were received. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $116.45 and 20% of that is $17.71. 

You have been asked to pay the total coinsurance amount of $17.71 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on March 26, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve proton beam therapy for the enrollee.  You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee can be successfully treated with standard radiation treatment measures.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability. For this particular enrollee, it appears that her obesity has resulted in a large, hemicircumferential field that extends medially above the sternum and laterally to the postero-lateral region. As a result, the intensity modulated radiation therapy (IMRT) plan is exposing the heart and lungs to high doses of radiation.  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 therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy for the enrollee.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) and additional procedures to construct a new crown under existing partial denture framework (D2971) provided June 23, 2021.  You asked the Plan to pay for the bitewing x-rays and additional procedures to construct a new crown under existing partial denture framework. You say that the dental work was necessary, and the x-ray was necessary to do the work. The Plan denied your request. The Plan says you have exceeded the frequency limit for the x-rays and the additional procedures to construct a new crown is not a covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the bitewing x-rays once per plan year.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing that bitewing x-rays were previously covered on April 13, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the additional procedures to construct a new crown under existing partial denture framework is not a covered service. Therefore, we decided that the Plan does not have to pay for the bitewing - single radiographic image (D0270) and additional procedures to construct a new crown under existing partial denture framework (D2971) provided June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials rendered on July 30, 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 are not covered.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies and materials) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials rendered on July 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy (97161) and occupational therapy (97165) services provided on July 23, 2021.  You asked the Plan to waive the copayment for the physical and occupational therapy services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 Outpatient Rehabilitation Services.     You have been asked to pay two $30 copayments for physical and occupational therapy services. Physical and occupational therapy services fall within the Outpatient Rehabilitation Services 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 physical therapy (97161) and occupational therapy (97165) services provided on July 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99203) provided on February 12, 2021.  You asked the Plan to pay for the outpatient office visit. You say that you would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.    Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on February 5, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided on February 12, 2021.