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

 We decided that the Plan does not have to pay for physician services (99199, & E1399) provided  May 10, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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.       We find that CPT codes 99199, & E1399 are not supported in the medical record. Specifically, the records do not detail what special service 99199 represents. Additionally, records do not show that a DME fitting was performed as represented by CPT code E1399. 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 (99199, & E1399) provided May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the incision and drainage of abscess (10061) provided on May 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the incision and drainage of abscess. You say that you would like this claim reprocessed based on the medical documentation. 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 incision and drainage of abscess (10061) provided on May 10, 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 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) and panoramic radiographic image (D0330) provided September 7, 2021.  You asked the Plan to pay for the 2D oral/facial photographic image and panoramic x-ray. You say that your provider told you the services would be covered. The Plan denied your request. The Plan says you have exceeded frequency limits for the panoramic x-ray and the 2D oral/facial photos are not covered.  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 panoramic x-ray is covered once every five years.  We looked at the file and Medicare rules. In this case the Plan has previously covered a panoramic x-ray. Based on this information, we decided that the Plan's frequency limit for panoramic x-rays has been exceeded. Though the Plan offers a dental benefit in excess of Medicare coverage, the 2D oral/facial photos are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350) and panoramic radiographic image (D0330) provided September 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on August 17, 2021.  

You asked the Plan to waive the copayment for the ambulance services. You say that you cannot be transported any other way because you have no feeling from the waist down. 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 $250 copayment for ambulance services.   

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless of the reason for the ambulance 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 ambulance services you received on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 12, 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 August 12, 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 electrical stimulation (G0283) neuromuscular reeducation (97112) Injection of drug/substance under skin or into muscle (96372) unclassified drugs (J3490) compounded drug, not otherwise classified (J7999) thiamine injection (J3411) pyridoxine injection (J3415) and vasopneumatic devices (97016) provided August 24, 2021 by an out of network 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 these services are not Medicare covered benefits.

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 electrical stimulation (G0283) neuromuscular reeducation (97112) Injection of drug/substance under skin or into muscle (96372) unclassified drugs (J3490) compounded drug, not otherwise classified (J7999) thiamine injection (J3411) pyridoxine injection (J3415) and vasopneumatic devices (97016) provided August 24, 2021 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infectious agent detection rendered on May 28, 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 procedure code 87506 is not supported.  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 87506 is infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.  We find that CPT code 87506 is not supported in the medical record. Specifically, the records do not support that 6-11 targets were tested. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection rendered on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory testing provided on March 31, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for lab services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and a valid referral was not 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 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 laboratory testing provided on March 31, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on July 26, 2021.  

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.  

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to unrelated to the terminal illness. Upon discharge or revocation, fee-for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  

The enrollee ended Medicare Hospice benefits on July 21, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on September 20, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you did all of teh tests that the doctor requested. 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 $150 copayment for CT scans.   You have been asked to pay a $150 copayment for the CT scan. 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 computed tomography (CT) scan you had on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge services rendered on April 8, 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 procedure code 99239 is not supported.  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 99239 is hospital discharge day management; more than 30 minutes.  We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of 31 minutes or more of hospital discharge day management services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered on April 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on May 7, 2019. 

 You asked the Plan to pay for ambulance service, basic life support, emergency transport. The Plan denied your request. The Plan says your claim was filed outside of the timely filing period and you have not supplied any additional information that supports a reversal of the initial decision.  

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  

The record shows that a claim for ambulance service, basic life support, emergency transport was not filed until May 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429, A0425) provided on May 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for partial dentures (D5214) received July 20, 2021.  You asked the Plan to pay for partial dentures. You say that you have dental coverage and want this covered by the Plan. The Plan denied your request. The Plan says partial dentures are not a covered benefit of the Plan.  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 partial dentures (D5214) received July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on  June 16, 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 the records provided do not support separate and unrelated stains.  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 88342 is "Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the medical records and billing records provided indicate 2 units of 88344 were also performed on June 16, 2021 and paid by the health plan. CPT 88342 has a bundled relationship with 88344 and the medical records provided do not include sufficient documentation to validate procedure 88342 26 (2 units) were unrelated to 88344,  therefore, no additional reimbursement is allowed. 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 not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 16, 2021.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for Fundus Photography provided on September 14, 2021.  You asked the Plan to pay for Fundus Photography. The Plan denied your request. The Plan says Fundus photography with interpretation and report is not covered by the Plan.  The Plan must follow Medicare rules. Medicare rules say Fundus Photography is not covered for routine screening.  We looked at the file and Medicare rules. Medicare says that Fundus Photography is not covered for routine screening. Therefore, we decided that the Plan does not have to pay for Fundus Photography provided on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the contact lenses purchased on April 20, 2021.   You asked the Plan to pay for the contact lenses. You say that this is the way you have always submitted it before, and you should be reimbursed $100. The Plan denied your request. The Plan says the eyewear was obtained from an out-of-network provider.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eyewear when received from a network provider.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Specifically, the contact lenses were not purchased from a network provider. Therefore, we decided that the Plan does not have to pay for the contact lenses purchased on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device and accessories to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve an OON pneumatic compression device and accessories. You say that the requested OON provider is the only brand you prescribe. You say that the requested OON provider accepts Medicare allowed rates. The Plan denied your request. The Plan says there are participating providers available who can supply the items that are needed.  

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device and accessories to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the specialist services rendered on October 22, 2021.  

You asked the Plan to waive the copayments for these services. You say that you do not understand why you have to pay a copayment for the injection and the office visit. 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 $35 copayment per provider per day for each Medicare-covered specialist office visit.   

Review of the file shows that you received specialist services on October 22, 2021. You have been asked to pay a $35 copayment for these services. These services fall within the Medicare-covered specialist office visit 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 specialist services rendered on October 22, 2021.