Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from May 5, 2021, to June 7, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are questioning the costs for each re-entry for inpatient care. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $400 per day for days 1-4 and $0 per day after day 5 for each inpatient stay.     Dates of Service Copayment Total May 5, 2021 - May 11, 2021 $400 per day for 4 days $1600 May 19, 2021 - May 28, 2021 $0 $0 June 1, 2021 - June 7, 2021 $400 per day for 4 days $1600 TOTAL:  $3200  The record shows the enrollee had three separate inpatient stays. The Plan combined the two stays from May 5, 2021, to May 28, 2021, resulting in one set of copayments for that period. Therefore, the enrollee has been asked to pay $400 per day for the first four days of two inpatient stays. The total for all stays is $3200. Inpatient hospital services fall within the Inpatient Hospital Care 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 inpatient hospital services provided from May 5, 2021, to June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay an additional amount, up to the $250 allowance for eyewear provided on June 30, 2021.  You asked the Plan to pay an additional amount, up to the $250 allowance for the eyewear. The Plan denied your request. The Plan says that the claim processed correctly based on the out-of-network Medicare covered eyewear benefit.  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. The Plan covers these services with a $250 allowance for supplemental eyewear every year, In-Network and Out-of-Network.  We looked at the file and the Plan's rules. The file shows the Plan covers a $250 allowance for supplemental eyewear every year, In-Network and Out-of-Network. The file does not indicate that the eyewear was due to cataract surgery for Medicare-covered post-cataract eyeglasses. Based on this information, we decided that the Plan's rules for coverage of the eyewear have been met. Therefore, we decided that the Plan has to pay an additional amount, up to the $250 allowance for eyewear provided on June 30, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to issue reimbursement for the breast reconstruction surgery (19371) and the special services (99199 x 2) rendered by the out-of-network (OON) provider on May 14, 2021.  You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 issue reimbursement 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 issue reimbursement for these services. Therefore, we decided that the Plan does not have to issue reimbursement for the breast reconstruction surgery (19371) and the special services (99199 x 2) rendered by the out-of-network (OON) provider on May 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy services (97530) provided on May 20, 2021.  You asked the Plan to pay for code 97530. 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 the services of an OT shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OT services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services (97530) provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sanexas-neogen device services provided on March 24, 2021.  You asked the Plan to pay for the sanexas-neogen device services. 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 providers must report services correctly.   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 properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid.  The office visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable Evaluation and Management (EM) service by the same physician or other qualified health care professional on the same day of a procedure or other service. There is no documentation of any significant, separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service.  Based on this information, we decided that Medicare rules for coverage of the sanexas-neogen device services have not been met. Therefore, we decided that the Plan does not have to pay for the sanexas-neogen device services provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on February 22, 2019 and March 1, 2019  You asked the Plan to pay for code 99233. 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 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 code 99233 was not filed until March 5, 2020. 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 the subsequent hospital care (99233) provided on February 22, 2019 and March 1, 2019
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2021.  You asked the Plan to pay for the laboratory services. 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 as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on August 4, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042), muscle and/or fascia debridement (11043), bone debridement (11044), subsequent nursing facility care, per day (99309), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on July 11, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 subcutaneous tissue debridement (11042), muscle and/or fascia debridement (11043), bone debridement (11044), subsequent nursing facility care, per day (99309), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on July 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on July 13, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says out-of-network hearing services are not covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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 hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided August 18, 2021.  You asked the Plan to pay for the periodontal scaling and root planing. You say that you feel this should be covered as an enhanced level of a normal cleaning. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ConfirmMDx test provided on July 15, 2021.  You asked the Plan to pay for the ConfirmMDx test. You say that you wys the services rendered were not medically necessary.  The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is only covered for certain indications.  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 pay for the ConfirmMDx test. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee had an elevated Prostate Specific Antigen level of 5.9 ng/mL. The records do not document that the enrollee had undergone a previous cancer-negative prostate biopsy within 24 months and was being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. Therefore, the enrollee did not meet criteria for the services rendered.  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 ConfirmMDx test have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx test provided on July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from July 12, 2021, through July 26, 2021.  You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services from July 12, 2021, through July 26, 2021 are not medically necessary as the member was not receiving skilled care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. The enrollee did not require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided daily skilled services were not required. This enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from July 12, 2021, through July 26, 2021.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from July 12, 2021, through July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided on February 23, 2021.  You asked the Plan to pay for genetic testing. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because when a laboratory assays two or more genes in parallel it must be billed with a single procedure code.  The Plan must follow Medicare rules. Medicare rules say that a laboratory procedure producing multiple test results should be billed with a single procedure code.   We looked at the file and Medicare rules. This lab testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve walk in tub and split king bed with mattress (CPT code E1399).  You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says these items do not meet the definition of durable medical equipment as outlined by Original Medicare  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve walk in tub and split king bed with mattress (CPT code E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 28, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the $50 charge for the service you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for specialist visits.    You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 specialist visit provided on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided August 17, 2021.  You asked the Plan to provide additional payment for the periodic oral exam, dental cleaning, bitewing x-rays, intraoral x-rays and localized delivery of antimicrobial agents. You say that the Plan's brochure does not explain that your cost for out-of-network services would be different. The Plan denied your request. The Plan says you are responsible for the allowed amount paid by the Plan and the total cost billed by the out-of-network provider.  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 periodic oral exam, dental cleaning, bitewing x-rays, intraoral x-rays and localized delivery of antimicrobial agents when the services are medically necessary and reasonable. If you choose to see an out-of-network dentist you might be billed for charges above what the plan pays, even for services listed as $0 copayment.  We looked at the file and Medicare rules. In this case the Plan provided documentation showing that the allowed amount has been covered by the Plan for these services. Since the services were provided out-of-network you are responsible for the charges above what the Plan pays. Therefore, we decided that the Plan does not have to provide additional payment for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first radiographic image (D0220), and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381) provided August 17, 2021.   Your complaint about the brochure potentially not including complete information about your benefits 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for tissue debridement (11042) provided on November 20, 2020.  You asked the Plan to pay for tissue debridement. You say that your physician provided medically necessary service in good faith. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is a duplicate of a code that was already paid on claim number 21A380365400.  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 11042 is debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square centimeters or less.  We find that CPT code 11042 is not supported in the medical record. Specifically, this claim line is an exact duplicate of a claim line that was already paid by the Plan on another claim. Based on this information, we decided that Medicare rules for coverage of tissue debridement have not been met. Therefore, we decided that the Plan does not have to pay for tissue debridement (11042) provided on November 20, 2020.