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

We decided the Plan does not have to pay for out of network services provided on June 29, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 out of network services provided to the enrollee on June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapies provided on June 9, 2021, to June 23,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for outpatient therapies. You say that you were told a referral was not required. The
Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 outpatient therapies provided on June 9, 2021, to June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination (71045) provided on August 26,
2021.
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that
two separate radiologic examinations (71045) were provided on August 26, 2021 by the same provider. The
file shows that the Plan paid for one radiologic examination (71045) provided on August 26, 2021 for this
provider. Therefore, we decided that the Plan does not have to pay for the radiologic examination (71045)
provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204), the eye refraction (92015), and the scanning computerized ophthalmic diagnostic imaging (92134) rendered by the out-of-network (OON) provider on March 9, 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 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99204), the eye refraction (92015), and the scanning computerized ophthalmic diagnostic imaging (92134) rendered by the out-of-network (OON) provider on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) punch biopsies (11104, 11105) subcutaneous and intramuscular injection (96372) unclassified drugs (J3490) provided May 5, 2021.

You asked the Plan to pay for the injection services. You say that please review the documents and reprocess this claim for payment. The Plan denied your request. The Plan says the services provided is considered experimental and unproven and is not medically reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 

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. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) punch biopsies (11104, 11105) subcutaneous and intramuscular injection (96372) unclassified drugs (J3490) provided May 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on March 31, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for physical therapy. You say that you would like the Plan to reprocess and pay this claim. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are in-network providers available who could have provided these services.

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 physical therapy provided on March 31, 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 - problem focused (D0140) and
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of
mucoperiosteal flap if indicated (D7210) provided July 14, 2021.

You asked the Plan to pay for the limited oral exam and tooth extraction. You say that your coverage booklet
mentions oral surgery is covered. The Plan denied your request. The Plan says these services are not covered
under your Medicare and you do not have supplemental dental coverage.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation -
problem focused (D0140) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth
and including elevation of mucoperiosteal flap if indicated (D7210) provided July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a skin substitute graft to the trunk, arms, legs, total wound surface area (15271) and the palingen or palingen xplus, per square centimeter (Q4173) rendered by the out-of-network (OON) provider on November 18, 2020.

You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items/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 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 items/services at issue in this appeal. The Plan did not pre-approve the items/services 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 application of a skin substitute graft to the trunk, arms, legs, total wound surface area (15271) and the palingen or palingen xplus, per square centimeter (Q4173) rendered by the out-of-network (OON) provider on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee from
February 22, 2021, to May 10, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network services provided to the enrollee from February 22, 2021, to May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground ambulance services provided on August 8, 2021.
You asked the Plan to pay for the ground ambulance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were not medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ground ambulance services. Our reviewer says that the documentation does not support that the services provided were medically reasonable or necessary. Our physician reviewer found the enrollee was transported via ambulance from the airport to a hospital for a cardiology assessment. The enrollee was noted to be hemodynamically stable, with glasgow 15, patent airway, and no signs of injury. The enrollee's vitals were stable. No treatment was provided during transport. The documentation does not support that other means of transportation were contraindicated for this
enrollee. Therefore, the enrollee did not meet criteria for the services rendered. 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 ground ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ground ambulance services provided on August 8, 2021
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from March 6, 2019, to June 
22, 2019.

You asked the Plan to pay for the services provided. You say that the plan should not have recoupled any 
portion of the original payment. The Plan denied your request. The Plan says that items were inclusive to other 
charges.

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.

We looked at the file and the rules. The Plan states in their determination that the services were partially 
overturned. There were items that were denied for unbundling, and items were denied as the nature of service 
was unable to be determined. The Plan does not indicate what was overturned, nor do they indicate specifically 
which items where denied, and for what reason. The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request. Therefore, we decided that the 
Plan has to pay for the inpatient hospital services provided from March 6, 2019, to June 22, 2019.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 provided on March 24, 2021 to April 7, 2021.

You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). 

We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of "I". means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 provided on March 24, 2021 to April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on October 23, 2019.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay noncontracted providers at the preferred provider rate if services are not available from preferred providers in the 
service area. You say that the in-network benefits should be honored, and the claim processed for payment. The 
Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules also say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the Plan has not forwarded the 
medical records from the physical therapy visit. This means that we cannot verify the billed services at issue. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided on October 23, 
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance imaging (MRI) (70553) provided on November 4, 2020.
You asked the Plan to pay for the MRI (70553). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two separate MRI's (70553) were provided on November 4, 2020. The file shows that the Plan paid for one
MRI (70553) provided on November 4, 2020. Therefore, we decided that the Plan does not have to pay for the Magnetic resonance imaging (MRI) (70553) provided on November 4, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an assisted living facility.
You asked the Plan to pre-approve admission to an assisted living facility. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to an assisted living facility have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve admission to an assisted living facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on April 15, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says code 95999 is not a valid base code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 was billed to describe the train of four testing provided. Train of Four testing is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on April 30, 2021.

You asked the Plan to pay for the therapy services and vitamin injections. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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. Medicare 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 this information, we decided that Medicare rules for coverage of the therapy services and vitamin injections have not been met. Specifically, the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy. 

In addition, 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. Therefore, we decided that the Plan does not have to pay for the therapy services and vitamin injections provided on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on May 11, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing does not meet Medicare coverage criteria.
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 file shows that a cardiovascular gene panel was provided. We looked at the file and the rules. The testing services was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on April 13, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

The file shows that electrical nerve stimulation was provided. We looked at the file and the rules. It is inappropriate for a patient to visit his/her physician, physical therapist, or an outpatient clinic on a continuing basis for treatment of pain with electrical nerve stimulation. Based on this information, we decided that the Medicare ules for coverage have not been met. 

The file shows that a nutria-pharmaceutical injection was provided. We looked at the file, and Medicare rules. 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. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on April 13, 2021.