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

We decided that the Plan does not have to pay for office or other outpatient visit (99214) provided on March 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for office or other outpatient visit. You say that the services that were provided were medically necessary. 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 office or other outpatient visit (99214) provided on March 29, 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 home health services provided to the enrollee from January 4, 2021, to January 20, 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 provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We find that the denied home health services are not supported. The appropriate home health type of bill was not submitted in this case. 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 home health services provided to the enrollee from January 4, 2021, to January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cervical collar (L0180) provided on April 6, 2021.  You asked the Plan to pay for the cervical collar. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not submitted with an itemized shipping/billing invoice to indicate the specific supplies.  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 a valid proof of delivery. Specifically, the claim did not include an itemized shipping invoice to indicate the equipment that was delivered to the enrollee. 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 cervical collar (L0180) provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) and a
methylprednisolone acetate 40 mg injection (J1030) provided on September 17, 2021.
You asked the Plan to waive the copayment for the office visit and a methylprednisolone acetate 40 mg
injection. You say that the services should be covered as you've never had to pay more than $40. The Plan
denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment and 20% coinsurance for Physician/Practitioner services, including doctor's office visits and
Medicare Part B prescription drugs.
You have been asked to pay a $40 copayment for an office visit and a 20% coinsurance for the
methylprednisolone acetate injection (allowed amount $5.73 x 20% = $1.15). Office visits and
methylprednisolone acetate injections fall within the Physician/Practitioner services, including doctor's office
visits and 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 copayment
for an office visit (99214) and a methylprednisolone acetate 40 mg injection (J1030) provided on September
17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the crown provided on September 13, 2021.  You asked the Plan to pay more for the crown. You say that there is no dentist that will do a crown for less than $1,000 and the $1,541 charge should not be your responsibility. You say that you are looking for this charge to be paid at 50%. The Plan denied your request. The Plan says the claim processed correctly toward your out-of-network 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 Plan is only obligated to pay 50% of the allowed amount for a crown from an out-of-network provider. You are responsible for any amount over what the Plan pays to the out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the crown provided on September 13, 2021.   Your complaint about the false statement 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 services (S1015, S8301) provided on June 17, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.   We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 (S1015, S8301) provided on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on February 26, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says medical documentation was not provided.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 the lab services provided on February 26, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle brace (L1971) and heel stabilizer (L3170), provided on April 8, 2021.

You asked the Plan to pay for the ankle brace and heel stabilizer. You say that the items are medically necessary. The Plan denied your request. The Plan says there is not a valid physician order for these items.

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 a valid physician order for the supplies provided in this case. The treating physician confirmed they did not order this item for the member. 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 ankle brace (L1971) and heel stabilizer (L3170), provided on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
March 25, 2020, to March 28, 2020.
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 DRG was updated in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 189 (Pulmonary and respiratory edema). 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
review has determined that DRG 202: Bronchitis and asthma with CC/MCC was most appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from March 25, 2020, to March 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for allergy testing (86003) provided on November 25, 2020.  You asked the Plan to pay for allergy testing. You say that this is a covered service. The Plan denied your request. The Plan says this is not supported in the records.  The Plan must follow Medicare rules. Medicare rules say that the need for allergy testing should be based on the findings during a complete history and physical examination of the patient. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. The submitted records do not include a complete history and physical examination of the patient. Based on this information, we decided that Medicare rules for coverage of allergy testing have not been met. Therefore, we decided that the Plan does not have to pay for allergy testing (86003) provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (86077) provided on August 15, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE was exceeded.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 (86077) provided on August 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 15, 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 provider did not bill as required by Medicare coding regulations.  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 imaging services provided to the enrollee on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553), provided on July 4, 2021.  You asked the Plan to pay for the CGM and supplies. You say that the item was medically necessary. The Plan denied your request. The Plan says documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.  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 medical records do not show the member's physician discussed the purchased DME with the enrollee nor does it show medically necessity. 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) (K0554) and supplies (K0553), provided on July 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray (71046) provided July 22, 2021.  You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that a chest x-ray as part of a pre-operative examination, where there is an absence of signs or symptoms indicating
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by an 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.
You are 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 psychotherapy service (90837) rendered by an 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 hospital outpatient clinic visit (G0463) rendered by the
out-of-network (OON) provider on October 13, 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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON)
provider on October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services received on July 23, 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 do not support the services billed.  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 G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."  We find that procedure code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services received on July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for diagnostic mammography (G0279, 77066, 76642) rendered on September 29, 2021.  You asked the Plan to waive the copayment for diagnostic mammography. You say that you do not agree with your copayment. The Plan denied your request. The Plan says you were 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). Your contract with the Plan clearly says that you must pay a $150 copayment at an outpatient hospital setting for other outpatient diagnostic tests.   You have been asked to pay a $150 copayment at an outpatient hospital setting for diagnostic mammography. Diagnostic mammography 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 diagnostic mammography (G0279, 77066, 76642) rendered on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided on April 29, 2021.  You asked the Plan to pay for shoulder elbow wrist hand orthosis. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim is missing documentation required for payment.  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. Specifically, the documentation submitted does not show the provider discussed the ordered equipment with the enrollee. 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 shoulder elbow wrist hand orthosis (L3960) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder brace (L3960) and wrist brace (L3916), provided on May 6, 2021, and May 7, 2021.

You asked the Plan to pay for the shoulder brace and wrist brace. You say that the items were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.

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 medical records submitted do not show that the DEMPOS were discussed or needed. Therefore, we decided that the Plan does not have to pay for the shoulder brace (L3960) and wrist brace (L3916), provided on May 6, 2021, and May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoulder brace (L3960), provided on August 9, 2021.  You asked the Plan to pay for the shoulder brace. You say that the items are medically necessary. The Plan denied your request. The Plan says documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code.  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 indicate medical necessity for the purchased DME nor do they show the treating physician ordered or discussed the need for these items. 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 shoulder brace (L3960), provided on August 9, 2021.