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

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries (93880) provided on September 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic service. You say that the service was rendered appropriately in response to the enrollee's medical condition. You rely on the servicing facility to obtain referrals and/or pre-authorization for certain diagnostic procedures. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 duplex scan of extracranial arteries (93880) provided on September 3, 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 injection of drug/substance under skin or into muscle (96372) physical performance test or measurement (97550) therapeutic procedure (97112) vasopneumatic devices (97016) unlisted therapeutic procedure (97139) unclassified drugs (J3490) thiamine injection (J3411) pyridoxine injection (J3415) compound drug, not otherwise classified (J7999) provided on September 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the services are not covered under the Plan benefits. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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. 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. 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 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 injection of drug/substance under skin or into muscle (96372) physical performance test or measurement (97550) therapeutic procedure (97112) vasopneumatic devices (97016) unlisted therapeutic procedure (97139) unclassified drugs (J3490) thiamine injection (J3411) pyridoxine injection (J3415) compound drug, not otherwise classified (J7999) provided on September 8, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from August 11, 2020 to September 8, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that the Patient Driven Payment Model (PDPM) score billed indicates that the enrollee required strict isolation precautions during the 7-day lookback period, and there is no supporting documentation to confirm this as true.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.  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 supported by the medical records. Our reviewer found the enrollee is an 87-year-old woman who suffered a trimalleolar fracture of her left lower leg. A specimen collected on 8/11/2020 detected 2019-nCov_N1 and 2019-nCov_N2. The results were received on 8/17/2020. The enrollee was to stay in isolation for 14 days. On 8/17/2020 the enrollee "was treated in room due to changes in protocol." 08/25/2020 was the resident's 14th day in isolation. The Covid-19 panel was to be repeated and the "resident will be transferred out of isolation as soon as she doesn't have any more fever for 24 hours and no other signs and symptoms." It is noted that the enrollee was "recently still having elevated temp." The records do support that O0100M, isolation for active infectious disease, (i.e.symptomatic and/or have a positive test and are in the contagious stage, with highly transmissible or epidemiologically significant pathogens) applies in this case. The documentation supports that the enrollee required more than standard precautions.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from August 11, 2020 to September 8, 2020.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 27, 2021 by an out-of-network (OON) provider.

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 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 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 office visit provided on July 27, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an MRI provided on September 1, 2021.  You asked the Plan to waive the coinsurance for an MRI. You say that you were quoted as only owing $70 and now are being charged a lot more. 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 MRI's.      You received an MRI on September 1, 2021. The total allowed amount is $920.68 and 20% of that is $184.13. You have been asked to pay the total coinsurance amount of $184.13 for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and 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 an MRI provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional chiropractic treatment visits.  You asked the Plan to pre-approve chiropractic visits. You say that you need additional visits to address your back pain. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because there is no documentation of objective baseline measures or treatment goals, and you are receiving maintenance therapy.  The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care.   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 chiropractic visits. Our reviewer says that you do not meet the Medicare criteria for additional chiropractic care. Our physician reviewer found you have back pain. The records submitted do not indicate that there is a treatment plan. The requested services are maintenance therapy. Therefore, the requested services are not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional chiropractic treatment visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmology services provided on May 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the ophthalmology services. You say that the services provided were medically necessary. 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 the ophthalmology services provided on May 5, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for epidural injections (64483, 64484) provided on July 15, 2021.  You asked the Plan to pay for epidural injections. You say that there is not limitation on this service. The Plan denied your request. The Plan says this exceeds the frequency limitation for this service.  The Plan must follow Medicare rules. Medicare rules say that no more than 3 epidurals may be performed in a 6-month period of time.   We looked at the file and Medicare rules. The records show that the enrollee already had 3 separate dates of epidural injections in the six months prior to the services at issue. Based on this information, we decided that Medicare rules for coverage of epidural injections have not been met. Therefore, we decided that the Plan does not have to pay for epidural injections (64483, 64484) provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intraoral - periapical radiographic images (x-ray) (D0220, D0230), and bitewing x-ray (D0274), provided on August 24, 2021.  You asked the Plan to pre-approve the intraoral and bitewing x-rays. You say that the services should be covered. The Plan denied your request. The Plan says you have exceeded the maximum allowance for these 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the intraoral - periapical radiographic images (x-ray) (D0220, D0230), and bitewing x-ray (D0274), provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral radiofrequency ablation (RFA) C2-C3 and C3-C4 for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that this request is supported.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee has undergone 2 diagnostic medial branch blocks/facet joint blocks or RFA to the indicated spinal levels. There has not been the appropriate relief from the medial branch blocks to indicate this request. 

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 pre-approve bilateral radiofrequency ablation (RFA) C2-C3 and C3-C4 for the enrollee.
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 the enrollee needs a comprehensive rehabilitation team to ensure proper management. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute inpatient hospital stay with an interdisciplinary approach to rehabilitation care. While the enrollee needs physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 24, 2021 by an out-of-network (OON) provider.  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 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 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 laboratory services provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wrist-hand orthotic (L3908) provided on July 28, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the orthotic. You say that you need the braces in order to prevent surgery for carpal tunnel and you feel this should be reimbursed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 wrist-hand orthotic (L3908) provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 3, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you were not aware that you were going to be billed for this ambulance service. You also say that you explained that you were willing to drive yourself and would have signed a waiver in order to drive but it was not offered. The Plan denied your request. The Plan says the copayment amount 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 $250 copayment for Ambulance Services.

You have been asked to pay a $250 copayment for the ambulance service. The ambulance service falls within the Ambulance 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 the ambulance services provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for an X-ray and an ultrasound provided on August 5, 2021, and September 16, 2021.  You asked the Plan to waive the copayments for an X-ray and an ultrasound. You say that you disagree with the charges because you received the services in your primary care providers office. 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 a $125 copayment for X-rays and ultrasounds provided at an outpatient hospital facility.  The record shows that you received an X-ray at an outpatient hospital facility on August 5, 2021. Therefore, you are responsible to pay the allowed amount of $83.37, which is less than the $125 copayment.   The record shows that you received an X-ray at an outpatient hospital facility on September 16, 2021. Therefore, you are responsible to pay the allowed amount of $112.30, which is less than the $125 copayment.  The total amount you owe is: $195.67.   You have been asked to pay the total copayment amount of $195.67 for an X-ray and an ultrasound. An X-ray and an ultrasound fall within the outpatient diagnostic tests and therapeutic services and 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 copayments for an X-ray and an ultrasound provided on August 5, 2021, and September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 2, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that both you and the provider's office contacted the Plan to verify your dental coverage. The Plan denied your request. The Plan says the frequency limit for this service had been exceeded. The Plan also says that when you contacted the Plan you were advised correctly regarding your 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, bitewing x-rays are limited to one procedure per plan year. The record shows that you received bitewing x-rays (D0274) on April 8, 2021 and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 2, 2021.