Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections provided on August 24, 2021.  You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, Transcutaneous Electrical Nerve Stimulation (TENS), vasopneumatic device, Prolotherapy and vitamin injections. The Plan denied your request. The Plan says Medicare does not cover Prolotherapy. Prolotherapy is believed to stimulate the body's ability to heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative processes. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered, which is like acupuncture. The TENS device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic/vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. As non-covered services they are not a benefit when ordered by either a contracted or a non-contracted provider in any plan design.  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. The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes.   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. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes. Therefore, we decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, TENS, vasopneumatic device, Prolotherapy and vitamin injections provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical supplies (procedure code A4649) provided to the enrollee on September 29, 2021.  You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says this code cannot be unbundled 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, the CPT Code Manual definition of code A4649 is "Surgical supply; miscellaneous."  We find that CPT code A4649 is not supported in the medical record. Specifically, this code has a status indicator of "P" which means that no separate can be made for this code. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for surgical supplies (procedure code A4649) provided to the enrollee on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) and panoramic x-ray (D0330) provided on August 2, 2021.  You asked the Plan to pay for the intraoral complete series x-ray (D0210) and panoramic x-ray (D0330). The Plan denied your request. The Plan says your benefits have been exhausted.  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, you also have a maximum benefit of one of D0210, D0277 or D0330 every 36 months. The Plan paid for the panoramic x-ray (D0330) provided on September 18, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray (D0210) and panoramic x-ray (D0330) provided on August 2, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from September 1, 2020, to September 21, 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 that there was no signed documentation from a Licensed Nurse, Speech Therapist, Occupational Therapist, or Physical Therapist stating the enrollee's usual functional status.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  The plan did not make any specific argument as to which functional abilities are felt to be incorrectly scored. The plan has not provided enough evidence to claim that the assessment coding was not done correctly. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from September 1, 2020, to September 21, 2020.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on April 1, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on August 16, 2021.  You asked the Plan to pay for the SelectMDx testing. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage.  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, the SelectMDx testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Of note, per the diagnostics exchange, which is applicable to California labs, the SelectMDx testing is not covered. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral exam (D0140) and denture repair (D5520) provided on September 23, 2021.  You asked the Plan to pay for the dental services. You say that these services were necessary and should be covered. The Plan denied your request. The Plan says you did not enroll in the optional supplemental dental coverage and therefore do not have coverage through this plan for preventative and comprehensive dental services.  Medicare generally does not cover dental services. The Plan follows the same rule but offers an additional optional dental benefit for an additional premium.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that you did not enroll in the additional dental benefits for 2021. Therefore, we decided that the Plan does not have to pay for the limited oral exam (D0140) and denture repair (D5520) provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on August 13, 2021.  You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on August 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 9, 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. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 19, 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. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an orthosis (L3761) provided July 14, 2021.  You asked the Plan to pay for the orthosis. You say that this item was medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 provided records do not show that the ordering physician discussed the need for this 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 an orthosis (L3761) provided July 14, 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 August 19, 2021.  

You asked the Plan to pay for the CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says there is no valid physician order on file.  

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 or relevant medical records which support medical necessity for the supplies provided in this case. The records submitted do not indicate the treating physician prescribed or discussed the purchased DME with the Member, nor do they show medical necessity for the purchased equipment. 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 August 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for Freestyle Libre continuous glucose monitor sensors (K0553) provided on July 9, 2021.  You asked the Plan to pay for Freestyle Libre sensors. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment 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 medical documentation provided does not discuss the items at issue. 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 Freestyle Libre continuous glucose monitor sensors (K0553) provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolotherapy/acupuncture, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device; examinations before, during and/or after treatment provided to the enrollee on July 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 this is not a covered benefit.  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 the denied treatment is is not supported in the medical record. Specifically, we find that the physical therapy services (97112, G0283) at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the state of Oklahoma.   Additionally, the multiple drug codes reported on this claim (J3411, J3415, J3490, J7999) 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.   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 prolotherapy/acupuncture, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device; examinations before, during and/or after treatment provided to the enrollee on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device provided to the enrollee on August 19, 2021.  You asked the Plan to pay for the services. You say that this was not medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  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 the denied treatment is not supported in the medical record. Specifically a review of the file and the publicly available records shows that the physical therapy services (97016, 97112, G0283) at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the state of Oklahoma.   Additionally, the multiple drug codes reported on this claim (J3411, J3415, J3490, J7999) 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."  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 prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device provided to the enrollee on August 19, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravenous infusion and abdominal paracentesis rendered on May 12, 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 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 96365 is intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.  We find that CPT code 96365 is not supported in the medical record. Specifically, there is no documented start and stop time. Based on this information, we decided that Medicare rules for coverage of these services have not been met.   The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that one unit of procedure code P9047 (albumin infusion) was covered by the Plan. The further two units are duplicate claims and not covered. Billed code 49083 (abdominal paracentesis) was provided once and the professional charges have already been paid. 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 intravenous infusion and abdominal paracentesis rendered on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and coinsurance for primary care physician (PCP) office visits provided from June 29, 2021, to July 6, 2021.  You asked the Plan to waive the deductible and coinsurance for the PCP office visits. You say that your doctor was on vacation and you did not know the provider you saw was a specialist. The Plan denied your request. The Plan says the correct amount was applied to your deductible and the correct coinsurance was also 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 there is a $203 deductible which applies to certain items and services.  The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been fully met at the time the PCP office visits were received from June 29, 2021, to July 6, 2021. The file shows that the remaining $98.16 for the PCP office visit on June 29, 2021, was applied to your deductible.  You have also been asked to pay $20.13, which is 20% of the allowed amount for the PCP office visit on July 6, 2021 ($100.67 allowed amount x 20% coinsurance = $20.13). Since the file shows your deductible was met on your first visit, the 20% coinsurance now applies. The PCP office visits falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for primary care physician (PCP) office visits provided from June 29, 2021, to July 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on August 24, 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 not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 23 for an emergency room but the file shows that the services were performed in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the office visit rendered on August 24, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation (90792) provided on August 9, 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 $25 copayment for each Medicare-covered individual therapy session for outpatient mental health care.   You have been asked to pay a $25 copayment for the Medicare-covered individual therapy session for outpatient mental health care 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 psychiatric diagnostic evaluation (90792) provided on August 9, 2021.