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

 We decided that the Plan does not have to pay for the drug testing provided on August 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that you would like the claim reprocessed using the group national provider identifier (NPI). The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing provided on August 17, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 9, 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 separately payable.  The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient clinic visit provided on September 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. You say that the enrollee was seen for a follow-up visit. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.  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 outpatient clinic visit provided on September 16, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay an additional amount for the acute inpatient hospital services provided from September 10, 2021, to October 13, 2201.  You asked the Plan to pay an additional amount for the inpatient care. You say that the diagnosis codes have been supported. The Plan denied your request. The Plan says that a hospital claim audit has been completed.  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 Plan has not forwarded any explanation as to why this payment was recouped or why the services at issue do not meet Medicare criteria for coverage. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the recoupment of payment has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay an additional amount for the acute inpatient hospital services provided from September 10, 2021, to October 13, 2201.   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 physical therapy services (97016, 97112, 97750, G0283), compound drugs (J3411, J3415, J3490, J7999), and administration (96372) provided on August 12, 2021.  

You asked the Plan to pay for physical therapy services, compound drugs, and administration. You say that this was medically necessary. The Plan denied your request. The Plan says this is 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. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  

We looked at the file and Medicare rules. 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 exclusively with J7999, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of physical therapy services, compound drugs, and administration. have not been met. Based on this information, we decided that Medicare rules for coverage of physical therapy services, compound drugs, and administration have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97016, 97112, 97750, G0283), compound drugs (J3411, J3415, J3490, J7999), and administration (96372) provided on August 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery you had at an ambulatory surgery center on September 29, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that you shouldn't have to pay a second copayment because the doctor didn't remove all of the cataract the first time. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for outpatient surgery.   You have been asked to pay a $200 copayment for the outpatient surgery. This copayment applies each time you have surgery, regardless of the reason for the surgery. 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 outpatient surgery you had at an ambulatory surgery center on September 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 22 to June 28, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were previously covered. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on April 22 to June 28, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit from March 6, 2021, to March 8, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted as an inpatient. The Plan denied your request. The Plan says a physician never admitted the enrollee as an inpatient and the proper copayment was 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 $85 copayment for per visit to an emergency room.     You have been asked to pay a $85 copayment for the emergency room visit. Emergency room visit falls within the Outpatient hospital 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 emergency room visit from March 6, 2021, to March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit, outcome assessment, and x-rays received on September 16, 2021.  

You asked the Plan to pay for the office visit, outcome assessment, and x-rays. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.  

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit, outcome assessment, and x-rays received on September 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services provided on August 9, 2021.

You asked the Plan to pay for the transportation services. You say that this claim should be reprocessed based on the medical documentation. The Plan denied your request. The Plan says a sequela code cannot be listed as the primary, first listed or principal diagnosis on a claim.

The Plan must follow Medicare rules. Medicare rules say that coding regulations indicate that the condition or nature of the sequela is sequenced first. 

We looked at the file and Medicare rules. In this case, both diagnosis codes billed with the claim are sequela codes and are missing a diagnosis code that describes the condition or nature of the sequela. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation services provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a psychotherapy visit provided on March 4, 2021.  

You asked the Plan to waive the coinsurance for psychotherapy visit. You say that you feel that you are entitled to 80% of the claims you have filed. The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for out-of-network outpatient mental health care visit. The allowed amount of the claim is $146.67, resulting in a coinsurance amount of $73.34. Therefore, the Plan reimbursed you $73.33.  

You have been asked to pay 50% coinsurance for psychotherapy visit. Psychotherapy visit falls within the Outpatient Mental Health 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 coinsurance for a psychotherapy visit provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), limited oral evaluation - problem focused (D0140) and panoramic radiographic image (D0330) provided August 24, 2021.  You asked the Plan to pay for the cone beam CT scan, limited oral exam and panoramic x-ray. You say that you verified before the appointment that the provider is in-network. The Plan denied your request. The Plan says the cone beam CT scan is not covered. You have exceeded the frequency limit for the exam and x-ray.  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 two limited oral exams every year and one panoramic x-ray every five years.   We looked at the file and Medicare rules. In this case the Plan provided documentation showing that limited oral exams were previously covered on May 27, 2021, and June 7, 2021. A panoramic x-ray was previously covered on June 7, 2021. Based on this information, we decided that the Plan's frequency limits for coverage of the limited oral exam and panoramic x-ray have been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the cone beam CT scan is not among those covered services. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), limited oral evaluation - problem focused (D0140) and panoramic radiographic image (D0330) provided August 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided from February 3, 2021, to February 24, 2021.  

You asked the Plan to waive the copayments for the psychotherapy visits. You say that you were told that you would have no copayments for the therapy. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for Medicare-covered outpatient mental health care services.   

You have been asked to pay a $40 copayment for each of the psychotherapy visits. The psychotherapy visits fall within the "Outpatient mental health 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 copayments for the psychotherapy visits provided from February 3, 2021, to February 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rapid coronavirus test (87635) provided on August 30, 2021.  You asked the Plan to pay for the coronavirus test. You say that it is a requirement for you to have the test before you board. You say that it was not your decision. You also say that you feel you should be reimbursed for this. The Plan denied your request. The Plan says the coronavirus test is not covered.  The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as business establishments are not covered by Medicare.   We looked at the file and Medicare rules. This testing was required by the cruise line for the purposes of routine travel. Based on this information, we decided that Medicare rules for coverage of screening testing have not been met. Therefore, we decided that the Plan does not have to pay for the rapid coronavirus test (87635) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite (D2392), pontic (D6240), retainer crowns (D6750), and simple extraction (D7140) provided on August 2, 2021, and August 9, 2021.  You asked the Plan to pay for the resin-based composite, pontic, retainer crowns, and simple extraction. You say that you feel these procedures should have been classified as medical or emergency treatment. You also say that your accident has caused a severe financial hardship on you because you are on a fixed income and do not have the money to pay this full claim. The Plan denied your request. The Plan says your benefit has been exhausted.  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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on May 26, 2021 and your annual maximum benefit for 2021 has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392), pontic (D6240), retainer crowns (D6750), and simple extraction (D7140) provided on August 2, 2021, and August 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for assistant surgery services for the complex wound drainage (10180) provided on March 23, 2021.  You asked the Plan to pay for the assistant surgery services for the complex wound drainage (10180). You say that the claim denied as not medically necessary, but a physician assistant is required for the surgery. You say that the Plan failed to properly reimburse for this date of service. The Plan denied your request. The Plan says services of an assistant surgeon are not covered for this procedure.    The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 10180. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgery services for the complex wound drainage (10180) have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services for the complex wound drainage (10180) provided on March 23, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for a CT scan of the abdomen and pelvis without contrast (74176) provided on September 8, 2021.  You asked the Plan to pay for a CT scan of the abdomen and pelvis without contrast. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the enrollee also received a procedure coded 74177 on the same date of service and a procedure edit exists between codes 74176 and 74177.  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 billed codes on this claim are 74176 and 70450. There is not a National Correct Coding Initiative (NCCI) edit that exists between these two codes. The Plan states that the provider billed 74177 but has not forwarded any documentation to support this. The Plan has not supplied additional evidence as to why code 74176 is not supported. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for a CT scan of the abdomen and pelvis without contrast (74176) provided on September 8, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia service provided on July 8, 2021.

You asked the Plan to pay for anesthesia service. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this service is correct, because supporting records were not submitted to verify the service billed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due for a claim.

We looked at the file and Medicare rules. No supporting medical records were submitted to the Plan. The Plan requested records, but none were submitted. Without supporting records, you have not furnished sufficient information to determine that payment is due for this claim as it has been billed. Based on this information, we decided that Medicare rules for coverage of anesthesia service have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia service provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 16, 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 were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 16, 2021.