Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for miscellaneous supplies (Q0508) provided to the enrollee on June 5, 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 Medicare does not pay for a service included within another 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, we have confirmed that code Q0508 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for miscellaneous supplies (Q0508) provided to the enrollee on June 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640, U0003) provided July 27, 2020.  You asked the Plan to pay for the lab services. You say that the 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 code 87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640, and U0003 is not supported in the medical record. Specifically, the place of service listed on the claim form (81, laboratory) does not match the place of service detailed in the records (32, nursing facility). 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 (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640, U0003) provided July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (procedure code 99053) provided to the enrollee on March 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 denied code remains 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 99053 is "Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service."  We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 services (procedure code 99053) provided to the enrollee on March 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 12, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient therapy provided from January 26, 2021, through March 28, 2021.  You asked the Plan to waive the copayment for outpatient therapy. You say that you were informed physical therapy would be covered under her insurance and you thought there were no copayments under home health care. You say that you were never informed that they would be billing this way and you did not consent to this. 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). The enrollee's contract with the Plan clearly says that enrollees must pay $30 per day for Medicare-covered physical therapy services, $30 per day for Medicare-covered occupational therapy services and $30 per day for Medicare-covered speech language therapy services.   The enrollee has been asked to pay a total of $1,200 for the outpatient therapy. ($30/visit x 40 visits = $1,200). Outpatient therapy falls within the "Outpatient rehabilitation services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient therapy provided from January 26, 2021, through March 28, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on August 7, 2021.  You asked the Plan to waive the copayment for emergency room visit. You say that you were in the emergency room for 7 hours and did not have these services. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 copayment for emergency room visit.   You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency 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 copayment for an emergency room visit provided on August 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), intraoral - periapical first radiographic image (D0220), and limited oral evaluation - problem focused (D0140) provided May 24, 2021.  You asked the Plan to provide additional payment for the tooth extraction, intraoral x-rays and limited oral exam. You say that you would like the services covered. The Plan denied your request. The Plan says the claims have been processed correctly.  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 the tooth extraction with 55% coinsurance when provided out-of-network (OON). It also includes one intraoral x-ray per calendar year covered with 50% coinsurance when provided OON. You may be billed by the OON provider for any amount greater than the payment made by the Plan to the provider.  We looked at the file and Medicare rules. The Plan provided documentation showing that the Plan has covered 45% of the cost of the tooth extraction and 50% of the cost of the intraoral x-rays. Since the services were provided OON you are also responsible for the difference between the amount the Plan paid, and the total cost billed by the OON provider. Though the Plan offers dental benefits in excess of Medicare coverage, limited oral exams are not among those covered services. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction, intraoral x-rays and limited oral exam have not been met. Therefore, we decided that the Plan does not have to provide additional payment for the extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), intraoral - periapical first radiographic image (D0220), and limited oral evaluation - problem focused (D0140) provided May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a wrist-hand orthosis (L3908) provided on June 30, 2021, by an out-of-network provider.  You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 a wrist-hand orthosis (L3908) provided on June 30, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99205) provided on September 23, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that please review and reconsider these claims for payment approval. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99205) provided on September 23, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care office visit provided on August 19, 2021.  You asked the Plan to waive the copayment for primary care visit. You say that this visit was just for a COVID-19 test. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $5 copayment for primary care visit.   You have been asked to pay $5 copayment for primary care visit. Primary care visit falls 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 copayment for a primary care office visit provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the established patient domiciliary, rest home visit (99336) provided on July 30, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary, rest home visit. You say that it was medically necessary for the enrollee to receive the treatment by the doctor and you did not know that the facility failed to get preauthorization so you treated this enrollee anyway. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the established patient domiciliary, rest home visit (99336) provided on July 30, 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 nursing facility supervision (99380) provided on May 21, 2021.  You asked the Plan to pay for nursing facility supervision. You say that this was medically necessary. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of B indicates that payment for covered services is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Payment for the service at issue is bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of nursing facility supervision have not been met. Therefore, we decided that the Plan does not have to pay for nursing facility supervision (99380) provided on May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmology services provided on August 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for ophthalmology services. You say that this was necessary for the established patient. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization 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 ophthalmology services provided on August 26, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional supplies and materials provided from January 29, 2021, through February 17, 2021.  You asked the Plan to pay for the additional supplies and materials. You say that 99072 was established to report additional practice expenses during a Public Health Emergency including supplies and additional clinical staff time. You say that the claims should be reprocessed. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.  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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We find that CPT code 99072 is not supported in the medical record. Specifically, CPT code 99072 has a status indicator of B. This means that CPT code 99072 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the additional supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials provided from January 29, 2021, through February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on June 9, 2021, at an outpatient hospital facility.  You asked the Plan to waive the copayment for outpatient surgery services. You say that you were unaware that a large copayment would apply to the services at issue. The Plan denied your request. The Plan says the correct 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 $350 copayment for outpatient surgery provided at an outpatient hospital facility.   You have been asked to pay a $350 copayment for outpatient surgery 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 outpatient surgery services provided on June 9, 2021, at an outpatient hospital facility.   Your complaint about not being provided with information about your cost-sharing responsibilities by the hospital staff is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient diagnostic and surgical services coded as 99205, 52647, 77022, 77021, 76377, 72197, A4649, J7040, J1335, A9579 and S0020 provided April 8, 2021 by an out of network provider.  You asked the Plan to pay for the outpatient services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient diagnostic and surgical services coded as 99205, 52647, 77022, 77021, 76377, 72197, A4649, J7040, J1335, A9579 and S0020 provided April 8, 2021 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated scooter.  You asked the Plan to pre-approve a power operated scooter. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home.  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 a power operated scooter. Our reviewer says that the item is not medically necessary. Our physician reviewer found the Local Coverage Determination (LCD): Power Mobility Devices - L33789 states: "Group 2 POVs (K0806, K0807, K0808) have added capabilities that are not needed for use in the home. Therefore, if a Group 2 POV is provided it will be denied as not reasonable and necessary."  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power operated scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychological services provided on May 26, 2021.  You asked the Plan to pay for the psychological services. You say that this should be reviewed for medical necessity and approved for payment. The Plan denied your request. The Plan says there is no documentation consultation or attempt to consult with the primary/attending physician as required.  The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with or attempt to consult with the enrollee's primary care physician. This should be documented in the record.  In this case, no referring physician is listed on the claim or the note. The record does not include any documented consultation with the primary physician. Therefore, we decided that the Plan does not have to pay for the psychological services provided on May 26, 2021.