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

We decided that the Plan does not have to waive the coinsurance for the nuclear imaging scan provided on May 11, 2021.
You asked the Plan to waive the coinsurance for kidney imaging morphology (78708). You say that Medicare needs to pay more. The Plan denied your request. The Plan says you were charged the coinsurance 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 20% coinsurance for Outpatient Nuclear Medicine. You have been asked to pay 20% coinsurance for kidney imaging morphology (78708). The kidney imaging morphology (78708) falls within the Outpatient Nuclear Medicine 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 the nuclear imaging scan provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 pre-approve the monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee does not take insulin. There is no indication as to why a glucometer would not suffice for
blood glucose monitoring.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission and services in conjunction with a total knee arthroplasty (27447).
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says they have agreed to approve the total knee arthroplasty procedure; however, the requested subsequent inpatient care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is scheduled for a knee arthroplasty, which has been approved by the Plan. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning two or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied; the requested inpatient care is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission and services in conjunction with a total knee arthroplasty (27447).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain coded as 70450 provided January 28, 2021.
You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim is missing an appropriate modifier required for payment.
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 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) scan of the head or brain coded as 70450 provided January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine (E0601), provided on January 1, 2021.
You asked the Plan to pay for a CPAP machine. You say that the item was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained.
The Plan must follow Medicare rules. Medicare rules say that plans may require enrollees to obtain authorization before receiving services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device have not been met. Specifically, per your contract with the Plan, prior authorization is required for durable medical equipment. The record indicates that the member did not obtain prior authorization for this equipment. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) machine (E0601), provided on January 1, 202
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a catheter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the item is not covered. 
 
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. Therefore, we 
decided that the Plan does not have to pre-approve a catheter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided January 29, 2021, to 
January 30, 2021, billed with codes 99601 and 99602. 
 
You asked the Plan to pay for the home infusion services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says these services are not billed using 
valid codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes 99601 and 99602 have status indicators of "I" in the Physician Fee Schedule. This means that they 
are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusion services have not been met. 

Therefore, we decided that the Plan does not have to pay for the home infusion services provided January 29, 
2021, to January 30, 2021, billed with codes 99601 and 99602.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the continuous glucose monitor data analysis provided on May 7, 2021
You asked the Plan to waive the copayment for ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report (95251). You say that you paid for the same service on April 19, 2021 so you do not understand why you have another copayment. The Plan denied your request. The Plan says you were charged this copayment correctly for the separate service.
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 Physician Services, specialty care physician.
You have been asked to pay a $10 copayment for ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report (95251). This service falls within the Physician Services, specialty care physician benefit category. The record shows this service was provided. 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 continuous glucose monitor data analysis provided on May 7, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS, vasopneumatic device and vitamin injections 
provided on January 4, 2021. 
 
You asked the Plan to pay for TENS, vasopneumatic device and vitamin injections. You say that  The Plan 
denied your request. The Plan says a TENS device including supplies is not a Medicare covered benefit with 
the available information. Pneumatic compression vasopneumatic devices can be covered in the home or other 
outpatient setting only for the treatment of chronic venous insufficiency with venous stasis ulcers, and 
refractory lymphedema. Vitamin injections into the nerve and musculoskeletal structures are not a Medicare 
covered service. 

The Plan must follow Medicare rules. Medicare rules say that 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.  The rules say that beginning in July 2015, 
claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) 
code. 
 
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. Therefore, we 
decided that the Plan does not have to pay for TENS, vasopneumatic device and vitamin injections provided on 
January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle placement provided on February 25, 2021.
You asked the Plan to pay for the services provided. You say that separate procedures were performed. The Plan denied your request. The Plan says the service is not separately payable.
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 36000 is introduction of needle or intracatheter, vein. We find that CPT code 36000 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the needle placement provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), periodic oral
evaluation (D0120), crown (D2740), and core buildup (D2950), provided on April 1, 2021, and April 7, 2021.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the provider has opted out of Medicare.
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. Specifically, you obtained services from a provider who has opted out
of Medicare. This means the services are not covered benefits. Therefore, we decided that the Plan does not
have to pay for the periodontal maintenance (D4910), periodic oral evaluation (D0120), crown (D2740), and
core buildup (D2950), provided on April 1, 2021, and April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance services provided on February 9, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an appropriate modifier was not 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 76492 is ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. We find that when billed with code 76937, CPT code 76492 is not separately payable without an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance services provided on February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the spinal canal (72148) provided on February 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the MRI services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for the services provided by the OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the spinal canal (72148) provided on February 22, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from March 13, 2021, to March 20, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a fixed income and cannot afford the cost. 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 $320 copayment per day for day 1-5 for inpatient hospital care. There is a $1,600 out-of-pocket limit per stay.
You have been asked to pay a total of $1,600 ($320 copayment x 5 days +$1,600) for the inpatient hospital stay. The inpatient hospital stay falls within the Inpatient hospital 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 the inpatient hospital stay from March 13, 2021, to March 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on March 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 surgery services provided on March 18, 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 complete series of intraoral x-rays (D0210), preventive procedure (D1999), crown (D2740), or pay more for the comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided on April 15, 2021 by an OON provider.

You asked the Plan to pay for the complete series of intraoral x-rays, preventive procedure, crown, and to pay more for the comprehensive oral evaluation, and prophylaxis. You say that you were not advised at the beginning that the treating provider is under new ownership/management, and were not aware they were OON. The Plan denied your request. The Plan says the complete series of intraoral x-rays, preventive procedure, and crown are not covered services. The Plan also says that these services were performed by a non-participating provider, and you are responsible for the difference between the Maximum Allowable Fee and the amount the provider bills you for the 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, the complete series of intraoral x-rays, preventive procedure, and crown are not among those covered under this benefit. For the comprehensive oral evaluation and prophylaxis you are responsible for a 50% coinsurance for each, plus the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210), preventive procedure (D1999), crown (D2740), or pay more for the comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided on April 15, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist services provided on April 28, 2021.

You asked the Plan to waive the copay for the services provided. You say that you did not see a physician. The Plan denied your request. The Plan says the claim processed 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 $45 copay for physician specialist services. 

The file shows that you received services by an optometry specialist. You have been asked to pay a $45 copay for the services provided. The services fall within the physician services 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 copay for the specialist services provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on May 8, 2021.
You asked the Plan to pay for the service. You say that the services were medically necessary. The Plan denied your request. The Plan says screening tests without a valid medical diagnosis related to the health of the enrollee are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Thyroid stimulating hormone (TSH), is not authorized because it is not covered by Medicare as a screening tool. The test at issue in this appeal, the service, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) (CPT code 84443) provided to the enrollee on May 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porch wheelchair lift (E1399).
You asked the Plan to pre-approve a porch wheelchair lift. You say that this item is necessary for your spinal condition. The Plan denied your request. The Plan says this is not a covered item.
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 a porch wheelchair lift (E1399).