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

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 22,
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 non-urgent services were not authorized.
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 services provided to the enrollee on June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluations (D0140 x 2), initial periapical x-
rays (D0220 x 2), additional periapical x-ray (D0230), and bitewing x-rays (D0272) provided from September
13, 2021, to September 23, 2021.
You asked the Plan to pay for the dental services. You say that you had a broken tooth that was causing an
infection. You say that you had an x-ray done and were prescribed an antibiotic. You say that you went back in
because the tooth had broken further. You say that you needed another x-ray to ensure the dentist got all the
tooth remains out. You also say that the services should be covered. The Plan denied your request. The Plan
says 1 bitewing procedure is covered per plan year. The Plan says that the frequency limit has been exceeded.
The Plan also says that limited oral evaluations and periapical x-rays are not listed as covered 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, limited oral evaluations and periapical
x-rays are not among those covered under this benefit. The record shows that the Plan paid for a bitewing x-ray
that you received on September 13, 2021. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluations (D0140 x 2), initial periapical x-rays (D0220 x 2), additional periapical x-ray (D0230),
and bitewing x-rays (D0272) provided from September 13, 2021, to September 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Neuroplasty and/or transposition (64716) provided on May 19,
2021.
You asked the Plan to pay for code 64716. You say that the medical records support the billing of code 64716
provided on May 19, 2021. The Plan denied your request. The Plan says that the medical records do not
support the billing of code 64716 provided on May 19, 2021.
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 64716 is Neuroplasty and/or transposition; cranial nerve (specify).
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 code 64716. Our reviewer says that the medical records
support the billing of code 64716 provided on May 19, 2021. Our reviewer found the enrollee is with
osteoporosis and thyroid nodules and normocalcemic hyperpara. She had removal of the superior right and left
Parathyroid glands. She has dissection of the recurrent laryngeal nerves as part of the procedure. The operative
note described the dissection of the recurrent laryngeal nerves and given the surgery this is a reasonable
approach.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 64716 have been met. Therefore, we decided that the Plan has to pay for
the Neuroplasty and/or transposition (64716) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device therapy and vitamin injections provided
on June 10, 2021, and billed with codes G0283, 97750, 96372, 97112, J3490, and 97139.
You asked the Plan to pay for the Sanexas device therapy and vitamin injections. You say that you would like
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not
covered.
The Plan must follow Medicare rules. Medicare rules say that in order for physician-provided drugs to be
covered, the medical records must document the name of the drug administered as well as the dosage. The rules
also 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.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas device therapy and vitamin injections have not been met. Specifically, the record does
not contain documentation of the dosage and type of drug administered in each injection, which is required by
Medicare for these services to be reimbursed. Additionally, after 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. Therefore, we decided that the Plan does not
have to pay for the Sanexas device therapy and vitamin injections provided on June 10, 2021, and billed with
codes G0283, 97750, 96372, 97112, J3490, and 97139.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy (45380)
provided on September 20, 2021.
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that this was a
preventative service and should have a $0 copayment. The Plan denied your request. The Plan says this claim
was processed correctly, and your copayment was assessed in accordance with your contract.
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 surgery services provided in an outpatient hospital setting. The outpatient hospital services, or
outpatient surgery cost share will apply when a polyp removal or biopsy is conducted during a preventative
colorectal cancer screening
You have been asked to pay a $200 copayment for the colonoscopy with biopsy. The colonoscopy in question
included a biopsy and was provided in an outpatient hospital setting. 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 colonoscopy with biopsy (45380) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an orthosis and an injection provided on October 7, 2021.  You asked the Plan to waive the coinsurance for an orthosis and an injection. You say that the services were not covered, and it was medically necessary. The Plan denied your request. The Plan says the provider submitted a corrected claim and is no longer billing for the services that was denied. The proper copayment was applied to the orthosis and injection.  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% coinsurance for Durable medical equipment (DME) and a 20% coinsurance for related supplies and Part B drugs that are administered by a provider. The total amount allowed for the DME was $154 with a coinsurance of $30.80 ($154 total amount x 20% coinsurance). The total amount for the injection was $1.20 with a coinsurance of $0.24 ($1.20 total amount x 20% coinsurance). The total coinsurance for these services was $31.04 ($30.80 coinsurance + $0.24 coinsurance).  You have been asked to pay a 20% coinsurance for an orthosis and an injection. An orthosis falls within the Durable medical equipment (DME) benefit category. The injection falls within the Medicare Part B prescription drugs 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 orthosis and an injection provided on October 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy (90837) provided on March 1, 2021, to July 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for psychotherapy.. You say that you feel like you are being penalized for taking the patient at his word regarding his insurance situation. The Plan denied your request. The Plan says eligibility was not verified by the provider prior to rendering care, the provider is not a network provider, and services were performed 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 psychotherapy (90837) provided on March 1, 2021, to July 10, 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 prolotherapy, a transcutaneous electrical nerve stimulator
(TENS) and supplies, and a pneumatic device provided to the enrollee on July 8, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
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 the denied treatment and the way it was coded is not supported in the medical record. Specifically,
after a review of the file and the publicly available records, we find that physical therapy services at issue in
this case (97112, 97139, G0283) were rendered by an NP/PA who is not licensed to provide physical therapy in
the state of Oklahoma.
Additionally, 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 (J3490)
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 the services have not been met.
Therefore, we decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve
stimulator (TENS) and supplies, and a pneumatic device provided to the enrollee on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  October 1, 2021.  You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the claim processed with the correct $150 eyewear allowance.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan processed the claim with the correct $150 eyewear allowance, and you are responsible to pay the difference. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on July 27, 2021.
You asked the Plan to pay for the dental service. You say that when you went to the dentist all they did was
take your blood pressure. You say that they refused to treat you. You also say that you feel this amount is
unfair because you did not receive any dental services. The Plan denied your request. The Plan says
consultation is not listed as a covered service.
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, consultation is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation
(D9310) provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism, the Goof Proof Kit, the
delivery fee, and the sales tax purchased on August 19, 2021, from a provider who is not enrolled in the
Medicare program.
You asked the Plan to reimburse you for the seat lift mechanism, the Goof Proof Kit, the delivery fee, and the
sales tax. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your
request. The Plan says the provider 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 reimburse you for the seat lift mechanism, the
Goof Proof Kit, the delivery fee, and the sales tax purchased on August 19, 2021, from a provider who is not
enrolled in the Medicare program.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the head (70544) provided on September 2, 2021.  You asked the Plan to pay for the MRI of the head. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70544 and 70551  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, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the head (70544) provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on May 26, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that the laboratory services should have been included with the copayment of the annual exam. The Plan denied your request. The Plan says the annual wellness visit does not include lab test. 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 $10 copayment for Medicare-covered lab services.     You have been asked to pay a $10 copayment for the laboratory services. The laboratory services 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 copayment for laboratory services provided on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided February 19, 2021, to February 25, 2021.  You asked the Plan to waive the copayment for the inpatient hospital admission and services. You say that you were admitted to the hospital and feel you shouldn't have to pay the charges. 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 $325 copayment each day for days 1-5 each time you are admitted for Medicare-covered hospital care.   You have been asked to pay a total of $1,300 ($325 copayment x 4 days = $1,300) for the inpatient hospital admission and services. The inpatient hospital admission and services falls within the Inpatient hospital care benefit category. This means that you have been asked to pay less than or equal to 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 inpatient hospital admission and services provided February 19, 2021, to February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Continuous Glucose Monitor (CGM) supplies (K0553) provided on July 4, 2021.  You asked the Plan to pay for the CGM supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the equipment that was billed.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The records submitted do not include sufficient information to verify that the member's physician discussed the need for these supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the Continuous Glucose Monitor (CGM) supplies (K0553) provided on July 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99211) provided on June 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that this is supported in the records. The Plan denied your request. The Plan says this was not authorized.  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 an office visit (99211) provided on June 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 panoramic x-ray (D0330) provided on September 27, 2021.  You asked the Plan to pay for the panoramic x-ray. You say that this service should be covered by your benefit. The Plan denied your request. The Plan says you had a previous panoramic x-ray on June 28, 2021, which was covered at that time. Panoramic x-rays can only be covered once every three plan years.  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 can cover one panoramic x-ray every three plan years.  Though the Plan offers a dental benefit in excess of Medicare coverage, the panoramic x-ray is requested in a frequency that is not covered under this benefit. Documentation shows that you had a previous panoramic x-ray which was covered by the Plan within three plan years. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 27, 2021.