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

We decided that the Plan does not have to pay for the injection services coded 62320 provided on June 11,
2021.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are 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, we have confirmed that code 62320
for the injection services is a column II code to column I code 00790. 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 the injection services coded 62320 provided
on June 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services are no longer required, and the continuation of skilled nursing facility services are not medically necessary.

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 pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on
September 27, 2021 .

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out of network physician services provided to the
enrollee on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder irrigation procedure provided on July 20, 2021.

You asked the Plan to waive the copayment for the bladder irrigation procedure. You say that you should not be responsible for the copayment for an exam room for a minor procedure. The Plan denied your request. The Plan says you have been asked to pay 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 $350 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $350 copayment for the bladder irrigation procedure.

You have been asked to pay a $306.19 copayment for the bladder irrigation procedure. The bladder irrigation procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 bladder irrigation procedure provided on July 20, 2021.

Your complaint about the hospital's billing practice 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services required to get stronger and move better can be safely received in a different setting.

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 pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673).
You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary.
The Plan denied your request. The Plan says the item is not medically necessary.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for a pneumatic compression device (E0675 and E0673).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis and laboratory work provided on September 8, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the urinalysis and laboratory work. You say that the enrollee was switching over from traditional Medicare and was expecting the same level of coverage with this insurance. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows CPT code G0471 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the urinalysis and laboratory work provided on September 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 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 are not covered.

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.

The test at issue in this appeal, a molecular genetic screening, 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 the laboratory services rendered on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug administration services provided on June 14, 2021.

You asked the Plan to pay for the services provided. You say that this is the only code you use to administer this injection. The Plan denied your request. The Plan says there is a more appropriate code to describe 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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic. We find that CPT code 96401 is not supported in the medical record. The records show that the enrollee received a denosumab (Prolia) injection to treat osteoporosis.

The records do not show that the services at issue were provided as part of chemotherapy treatment. 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 drug administration services provided on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for treatments with a Sanexas device provided on May 10, 2021.
You asked the Plan to pay for treatments with a Sanexas device. You say that the treatment at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that 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. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.
Upon 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 who is not licensed to provide physical therapy in the State of Wisconsin. 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 treatments with a Sanexas device provided on May 10, 2021
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90832) provided on May 25 and July 6, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met because the medical documentation does not record a consultation with the enrollee's primary care or attending physician.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. 

We looked at the file and Medicare rules. The medical record documents that the provider has consulted with the enrollee's clinical care team. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. Therefore, we decided that the Plan has to pay for psychotherapy services (90832) provided on May 25 and July 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas treatment provided on May 12, 2021.

You asked the Plan to pay for the Sanexas treatment. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say 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. Medicare rules also state that in order for physician-provided drugs to be covered, the medical records must document the name of the drug administered as well as the dosage.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sanexas treatment have not been met. Review of the file and publicly available records, we find that the physical therapy services at issue in this case (97014, 97150 and 97139) were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Wisconsin. Payment for HCPCS/CPT codes J3490, J3411, J3420, J7999 and administration code 96372 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Therefore, we decided that the Plan does not have to pay for the Sanexas treatment provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 75710) provided to the enrollee on April 7, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code is considered inclusive to another code.
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 75710 is a column II code to column I code 37227. 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 (procedure code 75710) provided to the enrollee on April 7, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from May 1, 2021, to May 23, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that you were never informed there would be a copayment. The Plan denied your request. The Plan says you have been asked to pay 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 a $0 copayment per day, per admission for days 1-20 and a $160 copayment per day, per admission for days 21-100.
The enrollee has been asked to pay a $1,280 copayment for the SNF care. The SNF care falls within the
"Skilled nursing facility (SNF) care" benefit category. The record shows a previous SNF stay within the same
benefit period. See chart below.
Dates of Service Service SNF Days Copayment Day Count Member
Liability
April 21, 2021, to
April 27, 2021
SNF care 1-6 $0 6 $0
May 1, 2021, to
May 14, 2021
SNF care 7-20 $0 14 $0
May 15, 2021, to
May 23, 2021
SNF care 21-29 $160 8 $1,280
Total $1,280
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 the SNF care provided from May 1, 2021, to
May 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of bone (21025) provided by an out-of-network provider on July 26, 2021.

You asked the Plan to pay for an excision of bone. You say that you were not told that you would need to see an in-network provider to get approval. The Plan denied your request. The Plan says services were approved to be provided in-network.

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.

We looked at the file and Medicare rules. Based on this information, we decided that the enrollee went to an out-of-network provider and not the referred participating facility. Therefore, we decided that the Plan does not have to pay for an excision of bone (21025) provided by an out-of-network provider on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on September 1, 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 service 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 $45 copayment for each Medicare-covered specialist office visit. 

You have been asked to pay a $45 copayment for the Medicare-covered specialist office visit 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 office visit (99213) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on April 20, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that frequency codes 7 and 8 may be used when appropriate for provider-submitted claim adjustments/cancellations. 

We looked at the file and Medicare rules. The file shows that the adjusted claim was not billed with the required frequency code of 7. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies provided on July 13, 2021.

You asked the Plan to pay for the services provided. You say that these items are provided at your own cost. The Plan denied your request. The Plan says the codes are invalid for usage with Medicare.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The file shows that a tubing extension set, and infection control supplies were provided. We find that CPT codes S1015 and S8301 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these 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 supplies provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care provided on June 8, 2021.

You asked the Plan to waive the copayment for the wound care. You say that this was a wound check and not
surgery. You say there was never any discussion of a charge for this service. The Plan denied your request. The
Plan says you have been asked to pay 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 $200
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.

You have been asked to pay a $200 copayment for the wound care. The wound care falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. The record shows that wound care is considered a surgical procedure.

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 wound care provided on June 8, 2021.