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

We decided that the Plan does not have to pay for electrical stimulation (G0283) vasopneumatic device (97016) subcutaneous and intramuscular injection (96372) therapeutic procedure, one or more areas, each 15 minutes (97112) unclassified drugs (J3490) injection, thiamine hcl, 100 mg (J3411) injection, pyridoxine HCl, 100 mg (J3415) provided August 19, 2021.
You asked the Plan to pay for the outpatient services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the services provided are not covered under Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 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 Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) vasopneumatic device (97016) subcutaneous and intramuscular injection (96372) therapeutic procedure, one or more areas, each 15 minutes (97112) unclassified drugs (J3490) injection, thiamine hcl, 100 mg (J3411) injection, pyridoxine HCl, 100 mg (J3415) provided August 19, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on June 18, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the 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. In this case, the CPT Code Manual definition of code 21556 is excision, tumor, soft tissue of neck or anterior thorax, subfascial (e.g., intramuscular); less than 5 cm. We find that CPT code 21556 is not supported in the medical record. Specifically, the billed code does not most accurately describe the provided services. 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 surgery services provided on June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the trimming of dystrophic nails (G0127) rendered by the out-of-network (OON) provider on August 17, 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 trimming of dystrophic nails (G0127) rendered by the out-of-network (OON) provider on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) provided on June 13, 2021.
You asked the Plan to pay for services provided between 10:00 PM and 8:00 AM. You say that this is supported in the records. 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. Code 99053 has a status indicator of B and is not separately payable.
Based on this information, we decided that Medicare rules for coverage of services provided between 10:00 PM and 8:00 AM have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM (99053) provided on June 13, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on July 30, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 21 must be billed for services rendered to a registered inpatient. We looked at the file and Medicare rules. The claim for these services was billed with POS code 22 for outpatient hospital; however, the enrollee was under inpatient status for the date of service and the POS code should be 21. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refractions (92015) provided October 6, 2021.
You asked the Plan to pay for the eye refractions. You say that this service was medically necessary and should
be covered. The Plan denied your request. The Plan says the service was not rendered by a contract vision
provider and is non-covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services only when performed as a routine screening by a plan-contract
provider.
We looked at the file and the Plan's rules. The services were not performed as a routine screening by one the
plan contract vision providers. Based on this information, we decided that the Plan's rules for coverage of the
eye refractions have not been met. Therefore, we decided that the Plan does not have to pay for eye refractions
(92015) provided October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88304, 88312) rendered by the out-of-network (OON) provider on June 17, 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 laboratory services (88304, 88312) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental services (D0120 and D1110) and vision services (92014,
92250, 92310 and S0500) provided on June 24, 2021, through July 20, 2021.
You asked the Plan to pay for the dental and vision services.. You say that you would like reconsideration
because these services should be covered by the Plan. The Plan denied your request. The Plan says that the
dental services have not been billed correctly and your vision claim must go to the vision Plan.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. the Plan has not forwarded sufficient information to verify if the criteria for
coverage of these services have been met. Specifically, the Plan has not indicated what supplemental benefits
the member has, if their vision and dental coverage is active or why these services would not be covered. It is
the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the dental
services (D0120 and D1110) and vision services (92014, 92250, 92310 and S0500) provided on June 24, 2021,
through July 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00210) provided December 10, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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. We find that CPT code 00210 is not supported in the medical record. Specifically, a properly corresponding surgical procedure was not billed with the anesthesia code. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00210) provided December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is not the preferred brand.
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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence provided that you would have inadequate and suboptimal results with the other preferred brands. Examples of this would be: higher a1c or low blood glucose reactions due to inaccurate readings with a preferred brand. This data has not been provided. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on September 9, 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 laboratory services rendered by the out-of-network (OON) provider on September 9, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (93306) and the myocardial perfusion imaging (78452) provided on August 30, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 $300 copayment for Medicare-covered diagnostic radiology services provided at a freestanding clinic.
You have been asked to pay a $300 copayment for the Medicare-covered diagnostic radiology services provided at a free standing clinic. 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 transthoracic echocardiography (93306) and the myocardial perfusion imaging (78452) provided on August 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric services provided from
February 19, 2021, through February 28, 2021.
You asked the Plan to pay for inpatient psychiatric services. The Plan denied your request. The Plan says inpatient psychiatric services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the inpatient psychiatric services are not medically necessary and reasonable. Our physician reviewer found that based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any aggressive behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations. The health Plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this enrollee does not meet the criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric services provided from February 19, 2021, through
February 28, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 1, 2020, to August 7, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware you would owe this much. The Plan denied your request. The Plan says the correct copayment has been 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 $275 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $275 copayment per day for days 1-6. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,650 ($275 x 6 days =
$1,650)an 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 an inpatient hospital stay provided by a participating provider on August 1, 2020, to August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevator (E2300), attendant control (E2331), expandable controller (E2377, E2313, E2311), positioning wedge (K0108), backpack mount (K0108), camera (K0108), and camera mount (K0108) for a power wheelchair.
You asked the Plan to pre-approve the power wheelchair accessories. You say that the features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that items that are not primarily medical in nature are non-covered. Expandable controllers are only covered when medically necessary. An attendant control cannot be covered when an enrollee operated controller is also requested. 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 power wheelchair accessories. Our reviewer says that the requested features are not medically necessary. Our physician reviewer found the seat elevator, camera, camera mount, and backpack mount are not primarily medical in nature and are non-covered. Wheelchair cushion codes are all inclusive and a positioning wedge cannot be billed using code K0108. The records provided show that the requested expandable controller is not medically necessary. The record show that the enrollee is capable of using standard switches to operate the wheelchair's functions. An attendant control cannot be covered since a beneficiary-operated controller is also included. 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 power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevator (E2300), attendant control (E2331), expandable controller (E2377, E2313, E2311), positioning wedge (K0108), backpack mount (K0108), camera (K0108), and camera mount (K0108) for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0483) rendered by the
out-of-network (OON) provider on January 15, 2020.
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 drug testing services (80307, G0483) rendered by the out-of-network (OON)
provider on January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (74177) provided on April 14, 2021.
You asked the Plan to pay for a computed tomography scan. You say that this service was separate from other services. The Plan denied your request. The Plan says this cannot be separately paid without a modifier.
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 74177 is a column II code to column I code 74174, which was previously billed by the same provider for the same date of service and paid on a separate claim. 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 a computed tomography scan (74177) provided on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and a heel stabilizer (L3170) provided on August 11, 2021.
You asked the Plan to pay for an ankle-foot orthosis and a heel stabilizer. You say that the items 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. The rules state that DMEPOS is covered only when the information in the patient's medical record adequately supports the medical necessity for the item.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided medical records do not discuss the necessity of the items at issue. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) and a heel stabilizer (L3170) provided on August 11, 2021