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

 We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798) provided August 4, 2020.  You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes 87486, 87496, 87498, 87541, 87581, 87631, 87640, and 87798 are not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87631, 87640, 87798) provided August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on July 7, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions outside of the annual supplemental routine eye exam are not covered.  Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.    We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided on August 5, 2021 and September 15, 2021.  You asked the Plan to waive the copayment for physical therapy. You say that the provider had you come multiple times but could have ordered Velcro wraps through insurance. You say that you refuse to pay the copayments for the visits. The Plan denied your request. The Plan says the copayments applied correctly.  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 $40 copayment for each therapy visit.      You have been asked to pay a $40 copayment for each therapy visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). Physical therapy falls 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 provided on August 5, 2021 and September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulative treatment (98941) provided on July 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic service. You say that you did not know you needed to obtain prior authorization before you treated the enrollee. 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 chiropractic manipulative treatment (98941) provided on July 16, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (procedure code S9338) provided to the enrollee on March 9, 2021 and March 10, 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 this is an invalid procedure code for this 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, the CPT Code Manual definition of code S9338 is "Home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem."  

We find that procedure code S9338 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy services (procedure code S9338) provided to the enrollee on March 9, 2021 and March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies (S1015 and S8301) provided to the enrollee on June 17, 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 these are invalid procedure codes for this 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, the CPT Code Manual definition of the denied codes is:  S1015:  IV tubing extension set  S8301:  Infection control supplies, not otherwise specified  We find that procedure codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the codes are not valid for Medicare purposes. 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 the supplies (S1015 and S8301) provided to the enrollee on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 22, 2021.  

You asked the Plan to waive the copayment for these services. You say that you did not have an outpatient visit on this date. The Plan denied your request. The Plan says the copayment was applied correctly.  

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 services obtained from a specialist.   

Review of the file shows that you received specialist services on June 22, 2021. You have been asked to pay a $25 copayment for these services. These services fall within the services obtained from a specialist benefit category. The file shows that you received services from this provider while receiving outpatient surgical services. 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 specialist services rendered on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the follow-up visit and x-ray provided in the orthopedic surgeon's office on August 23, 2021.  You asked the Plan to waive the cost sharing for the follow-up visit and x-ray. You say that you feel that this copayment should be waived since it should be included in your prior visit. The Plan denied your request. The Plan says you were seen in a specialist office, which carries a $20 copayment per your EOC. This was correctly applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for office visits to specialists.   You have been asked to pay a $20 copayment for the follow-up visit and x-ray. The follow-up visit and x-ray fall within the office visits to specialists 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 cost sharing for the follow-up visit and x-ray provided in the orthopedic surgeon's office on August 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for bilateral upper or lower extremity arterial assessments to check blood flow in relation to a blockage provided on February 18. 2021.  You asked the Plan to pay for bilateral upper or lower extremity arterial assessments to check blood flow in relation to a blockage. The Plan denied your request. The Plan says that the Plan cannot determine if a physician's order was given, how the member came to you, the referring provider, and/or whether the services are necessary. All providers are required to furnish necessary information to the health Plan when requested.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for bilateral upper or lower extremity arterial assessments to check blood flow in relation to a blockage provided on  February 18. 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the emergency room (ER) visit provided on March 8, 2021, and the allergy specialist visit provided on March 18, 2021.  You asked the Plan to waive the copayments for the ER visit and allergy specialist visit. You say that You should not have these charges since they are related to your coronavirus vaccine administration. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $90 copayment for each emergency room visit.  Your contract with the Plan also clearly says that you must pay a $50 copayment for each specialist office visit.  You have been asked to pay a $90 copayment for the ER visit. ER visits fall within the Emergency Care benefit category. You have also been asked to pay a $50 copayment for the allergy specialist visit. Allergy specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 the emergency room (ER) visit provided on March 8, 2021, and the allergy specialist visit provided on March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy provided on July 27, 2021.  

You asked the Plan to pay for the infrared therapy. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says codes 97110, 97140 have been overturned. The Plan also says that the infrared therapy remains denied.    

The Plan must follow Medicare rules. Medicare rules say that effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared therapy provided on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for treatment of ankle fracture (27786) provided on June 2, 2021.  You asked the Plan to pay for treatment of ankle fracture. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code has a medically unlikely edit value of 1 meaning that no more than 1 unit is payable.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 27786 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of treatment of ankle fracture have not been met. Therefore, we decided that the Plan does not have to pay for treatment of ankle fracture (27786) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing provided between April 12, 2021, and July 19, 2021.  You asked the Plan to pay for the lab testing. You say that physicians rely on the timely laboratory results provided by your company to determine or adjust course of treatment and prevent/reduce hospitalizations. The Plan denied your request. The Plan says laboratory testing is included in the payment made to the ESRD facility.  The Plan must follow Medicare rules. Medicare rules say that Medicare requires that lab testing related to ESRD be reported by the ESRD facility directly, even if provided under arrangements.   In this case, the lab testing at issue was not reported by the ESRD facility directly. This is required even if the testing is provided by an external provider. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided between April 12, 2021, and July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for an injection (66020) provided on April 26, 2021.  You asked the Plan to pay for an injection. You say that this is separately payable. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare payment policy does not allow separate payment for procedures including the "separate procedure" designation in their code descriptor when the "separate procedure" is performed with another procedure in an anatomically related area.  In this case, the CPT Code Manual definition of code 66020 is injection, anterior chamber of eye (separate procedure); air or liquid.  We find that CPT code 66020 is not supported in the medical record. Specifically, this cannot be paid because it was billed and performed with another procedure in an anatomically related area. Based on this information, we decided that Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection (66020) provided on April 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided on May 10, 2021.  You asked the Plan to pay for the skilled nursing services. You say that this is a home infusion pharmacy suite, and the facility uses HCFA claim forms for the services billed. You say that the claim is payable and no UB claim form is needed. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that institutional providers, including home health agencies, use one of two institutional claim formats to bill Original Medicare.    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided outside the United States on April 24, 2021 to July 28, 2021.  You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan denied your request. The Plan says coverage criteria has not been met.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.    We looked at the file and Medicare rules. No medical records were obtained for dates of service May 25, 2021 or July 28, 2021. It cannot be determined if these services were emergent without medical records. Furthermore, the plan has paid the allowable amounts for the remaining dates of service. Expenses for obtaining medical records is not a covered expense.  Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided outside the United States on April 24, 2021 to July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician (D9310) and intraoral x-ray (D0220) provided on August 26, 2021.  You asked the Plan to pay for the consultation and x-ray. You say that these services are medically necessary. The Plan denied your request. The Plan says a diagnostic consultation is not a covered service under your dental benefit. The intraoral x-ray is an eligible service, but the benefit has a limitation of one intraoral x-ray per calendar year. You had a previous x-ray in July of 2021, and the benefit for this service was exhausted on the date in question. Therefore, these services are denied.  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. Services not listed in the dental benefits chart are not covered. The Plan can cover one intraoral x-ray procedure code per calendar year.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested diagnostic consultation is not among those covered under this benefit. In addition, there is a limit to one intraoral x-ray per calendar year. Documentation shows you have had a previous intraoral x-ray in 2021, which was covered by the Plan at that time. Therefore, we decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician (D9310) and intraoral x-ray (D0220) provided on August 26, 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) and intraoral - periapical each additional radiographic image (D0230) provided May 13, 2021.  You asked the Plan to pay for the intraoral x-rays. You say that no one informed you that an extra, uncovered procedure was being performed. The Plan denied your request. The Plan says these x-rays are not covered under 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic image (D0230) provided May 13, 2021.