Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admissions and services provided from June 17, 2021, to June 23, 2021, and from June 24, 2021, to July 1, 2021.  You asked the Plan to waive the copayment for the inpatient hospital admissions and services. You say that you thought hospital stays were covered at 100% and were not aware that there would be a copay in 2021. The Plan denied your request. The Plan says the copayments were applied correctly up to your maximum out-of-pocket amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment each day for days 1-5 each time you are admitted for Medicare-covered hospital care. The most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 2021 is $2,000.  You have been asked to pay a total of $1,625 ($325 copayment x 5 days = $1,625) for the inpatient hospital admissions and services provided June 17, 2021, to June 23, 2021. You have been asked to only pay a total of $278.87 as your copayment for the inpatient hospital admission and services provided June 24, 2021, to July 1, 2021, because this was the amount remaining in your out-of-pocket maximum for 2021. The inpatient hospital admissions and services falls within the Inpatient hospital care 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 the inpatient hospital admissions and services provided from June 17, 2021, to June 23, 2021, and from June 24, 2021, to July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided on August 31, 2021 and billed with CPT codes 97112, 97139, 97016, 99213, 96372, J3411, J3415 and J7999.  You asked the Plan to pay for the Sanexas device therapy and vitamin injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is not a Medicare covered benefit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas device therapy and vitamin injections have not been met. Payment for HCPCS/CPT codes 96372, J3411, J3415 and J7999 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. After review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. 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.   Therefore, we decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided on August 31, 2021 and billed with CPT codes 97112, 97139, 97016, 99213, 96372, J3411, J3415 and J7999.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit (99213-25) provided on May 5, 2021.

You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service is included in the osteopathic manipulation global package.

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. Specifically, the record clearly indicates that the Plan reviewed medical records to confirm that CPT code 99213 was not a distinct and separate service from the osteopathic manipulation. The Plan has not forwarded any medical records for review. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the office visit (99213-25) provided on May 5, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray
(D0220) provided on September 20, 2021.
You asked the Plan to pay for the limited oral evaluation. You say that you were advised this provider was in
network. You say that you checked with the plan and the provider's office. You also say that these services fit
under comprehensive. The Plan denied your request. The Plan says limited oral evaluation is not listed as 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, limited oral evaluation is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral
evaluation (D0140) and periapical x-ray (D0220) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established
patient (D0150) provided August 3, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you would like this service covered.
The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the
comprehensive oral exam once very three calendar years.
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
exam was previously covered on July 12, 2021. Based on this information, we decided that the Plan's frequency
limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does
not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 3,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolotherapy and transcutaneous electrical nerve
stimulation (TENS) therapy rendered on July 1, 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 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. The rules say that TENS therapy for chronic low back pain (CLBP) is covered when the
beneficiary is enrolled in an approved clinical study meeting specific requirements.
We looked at the file and Medicare rules. The file shows that the TENS therapy and prolotherapy were not
performed for the treatment of low back pain in the setting of a an approved clinical study. Based on this
information, we decided that the rules for coverage of the acupuncture services have not been met. Therefore,
we decided that the Plan does not have to pay for the prolotherapy and transcutaneous electrical nerve
stimulation (TENS) therapy rendered on July 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76942) provided on May 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76942 is a column II code to column I code 36556. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (76942) provided on May 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the abdomen (76705)
provided on September 28, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the provider told you this service
would be covered in full, and you would not have had this service done if you knew there would be a
copayment. The Plan denied your request. The Plan says this service was covered as medically necessary, and
your copayment was assessed in accordance with your contract. Ultrasounds performed at a freestanding
provider's office require a $25 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for Medicare-covered ultrasounds at a freestanding provider.
You have been asked to pay a $25 copayment for the ultrasound. 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 ultrasound of the abdomen (76705) provided on September 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient psychiatric services provided to the enrollee from June 27, 2021, to July 20, 2021.  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 there are no medical records to support further care needs at an inpatient level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based on a review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time, as she did not have dangerousness to self or others and was not showing any auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric services provided to the enrollee from June 27, 2021, to July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network
(OON) provider on September 3, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 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 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 (99213) rendered by the out-of-network (OON) provider on
September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), and intraoral - complete series of radiographic images (D0210) provided September 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the dental cleaning, periodic oral exam and complete series of intraoral x-rays. You say that you feel some money should be paid by the Plan even though the services were provided OON. The Plan denied your request. The Plan says the services were provided OON, and you have exceeded the frequency limit for the dental cleaning.  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 dental cleaning and periodic oral exam once per plan year. If you see an out-of-network dentist, you are responsible for the difference between the contracted amount and the total fees charged by the dentist.   We looked at the file and Medicare rules. The Plan provided documentation showing that a dental cleaning was previously covered on March 11, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the dental cleaning has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the complete series of intraoral x-rays is not a covered service. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) or complete series of intraoral x-rays provided September 21, 2021. The Plan also provided documentation showing that they paid 50% of the contracted amount for the periodic oral exam. You are responsible for 50% of the contracted amount plus the difference between the contracted amount and the total cost charged by the OON dentist. Therefore, we decided the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120) provided September 21, 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 limited oral evaluation (D0140), periapical x-ray (D0220), and bone replacement graft (D7953) provided on September 23, 2021.  You asked the Plan to pay for the dental services. You say that the $200 allowance should be applied to the services. The Plan denied your request. The Plan says the services you received are not covered. The Plan also says that you signed a Pre-Service Estimate that showed what you should expect to pay for the services rendered.  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 limited oral evaluation, periapical x-ray, and bone replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and bone replacement graft (D7953) provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pharmacogenomic testing provided on August 16, 2021.  You asked the Plan to pay for the pharmacogenomic testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has not been billed correctly.  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, the pharmacogenomic testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the use of any specific drug. Therefore, we decided that the Plan does not have to pay for the pharmacogenomic testing provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for injections provided on January 10, 2019.  You asked the Plan to waive the copayment for the injections. You say that you were told the services that were provided was paid for already. You did not receive any notice about the copayment. The Plan denied your request. The Plan says the proper copayment was applied for this service.  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 $295 copayment for all other Ambulatory Surgical Center (ASC) services.     You have been asked to pay a $295 copayment for the injections. The injections falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for injections provided on January 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on April 2, 2021, through May 2, 2021.  You asked the Plan to pay for the CGM and supplies. You say that the item is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed code; nor did it indicate the provider discussed the need for the billed code.  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 relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted does not indicate medical necessity; nor does it indicate the provider discussed the need for the purchased DME. 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 the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on April 2, 2021, through May 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on September 27, 2021.  You asked the Plan to pay for the x-rays. You say that these services were necessary. The Plan denied your request. The Plan says bitewing x-rays are covered once per year. You previously had bitewing x-rays on June 8, 2021, which were covered at that time.  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 can cover one set of bitewing x-rays per plan year.   Though the Plan offers a dental benefit in excess of Medicare coverage, the bitewing x-rays are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the Plan paid for a previous set of bitewing x-rays for you in 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing
provided on April 27, 2021.
You asked the Plan to pay for the FISH testing. You say that you would like reconsideration because this
testing was medically necessary. The Plan denied your request. The Plan says FISH testing is not a covered
benefit for the diagnosis as listed on the claim.
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, the FISH testing, was requested solely for screening purposes. Medicare does
not cover this test solely for screening purposes. Of note, the documentation submitted did not include any
clinical information. Without medical records, we are unable to determine why this testing was ordered or how
it would affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the
fluorescence in situ hybridization (FISH) testing provided on April 27, 2021.