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

We decided that the Plan does not have to pay for the laboratory service (81479) rendered by the out-of-network (OON) provider on April 7, 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 laboratory service (81479) rendered by the out-of-network (OON) provider on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services associated with the Sanexas procedure (G0283, 97016, 97150, 96372, J3490, J3411, J3415, J3420) provided on May 7, 2021.

You asked the Plan to pay for the medical services. You say that you would like these services reprocessed for medical necessity. The Plan denied your request. The Plan says no payment will be made for these services as they utilized improper billing practices.

The Plan must follow Medicare rules. Medicare rules say that billed medical services are subject to the criteria listed in the Medicare rules section. 

Therapy Services Billed as G0283, 97016, 97150

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. These services will not be covered according to Medicare rules.

Drug Services Billed as 96372, J3490, J3411, J3415, J3420

The multiple drug codes reported on this claim refer to a pre&#8208;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. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services associated with the Sanexas procedure (G0283, 97016, 97150, 96372, J3490, J3411, J3415, J3420) provided on May 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services (20930, 20936, 63047, 63048, and 
22830) provided on July 22, 2021.

You asked the Plan to pay for codes 20930, 20936, 63047, 63048, and 22830. You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Codes 
20930 and 20936 have a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) 
and no separate payment is made for these codes under the fee schedule as payment is bundled into the 
payment for the services to which these codes are incident to.

We have also confirmed that codes 63047 and 22830 are column II codes to column I code 22633. 
Additionally, we have confirmed that code 63048 is an add-on code. As the primary procedure code, 63047, is 
not payable in this case, the add-on code is also not payable.

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 surgical services (20930, 20936, 63047, 63048, and 22830) provided on July 22, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas machine along with subcutaneous vitamin injections (CPT code(s): G0283-GP, 97150-GP, 96372, J3490, J3490-KP, J3490-KQ, J3411, J3415, J3490-59 x3, J3420) provided to the enrollee on May 5, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy in the State. 

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 Sanexas machine along with subcutaneous vitamin injections (CPT code(s): G0283-GP, 97150-GP, 96372, J3490, J3490-KP, J3490-KQ, J3411, J3415, J3490-59 x3, J3420) provided to the enrollee on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on September 1, 2021.

You asked the Plan to pay for the dental services. You say that you contacted the plan after receiving the denial. You say that you were advised that your dental coverage was terminated in 2020. You say that you did not receive notification of the change in coverage. You also say that you did not request this change. The Plan denied your request. The Plan says routine dental services are not covered. The Plan also says that you did not enrollee in the optional dental rider.

Medicare generally does not cover dental services. The Plan follows the same rule.

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. among those covered under this benefit. Additionally, though the Plan offers an optional supplemental dental benefit in excess of Medicare coverage, the file shows that you were not enrolled in the optional dental rider on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on September 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination services (73120) provided on July 22, 2021.
You asked the Plan to pay for code 73120. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 73120 is a column II code to column I code 73130. 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 radiologic examination services (73120) provided on July 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and related services (99214, 93000, 93306) provided on June 2, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit and related services. You say that the enrollee did not provide the correct insurance information. The Plan denied your request. The Plan says this was not authorized.

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 an office visit and related services (99214, 93000, 93306) provided on June 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on May 4, 2021.

You asked the Plan to pay for the therapy services and vitamin injections. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

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 say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services and vitamin injections have not been met. Specifically, the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy. In addition, 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 the therapy services and vitamin injections provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82306) provided August 18, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is 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, vitamin testing, 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 lab services (82306) provided August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic mammography provided on August 4, 2021.

You asked the Plan to pay for the services provided. You say that the report supports separate services. The Plan denied your request. The Plan says there is no additional payment for the code.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.

In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic mammography provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided August 27, 2021.

You asked the Plan to pay for the fluoride varnish. You say that you do not understand why fluoride is not covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided August 27, 2021.

Your complaint about the Plan excluding fluoride from the optional supplemental dental benefit 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis coded 77062 provided on January 29, 2021.

You asked the Plan to pay for the diagnostic digital breast tomosynthesis. 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 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 77062 is diagnostic digital breast tomosynthesis; bilateral.

We find that CPT code 77062 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis coded 77062 provided on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on April 
26, 2021.

You asked the Plan to pay for the therapy services and vitamin injections. You say that the medical records 
should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says the 
services are considered experimental/investigational and therefore, 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 say that claims for 
compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services and vitamin injections have not been met. Specifically, the physical therapy 
services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical 
therapy. 

In addition, 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 the therapy services and vitamin injections provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on May 17, 2021.

You asked the Plan to pay for the moderate sedation 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 supported by the documentation.

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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on May 12, 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 services provided to the enrollee on 
May 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, chest (71046),
electrocardiogram, routine ECG with at least 12 leads (ECG) (93000), and duplex scan of extremity veins
including responses to compression and other maneuvers (93971) provided July 29, 2021.
You asked the Plan to waive the copayment for the chest x-ray, ECG and ultrasound study of one arm or leg
veins. You say that you would the Plan to cover these services. The Plan denied your request. The Plan says the
cost-sharing has been 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 $45
copayment for basic radiological services provided in a specialist's office or freestanding radiological facility.
You have been asked to pay a $30.52 copayment for the chest x-ray, $14.34 for the ECG and $45 for the
ultrasound study of one arm or leg veins. These services fall within the Outpatient diagnostic tests and
therapeutic services and supplies benefit category. This means that you have been asked to pay less than or
equal to 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 radiologic examination, chest (71046), electrocardiogram, routine ECG with at least 12
leads (ECG) (93000), and duplex scan of extremity veins including responses to compression and other
maneuvers (93971) provided July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80053) provided August 18, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this testing was performed for screening purposes and is non-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 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 lab services (80053) provided August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on May 6, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services
are investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that electrical nerve stimulation was provided. We looked at the file and the rules. It is
inappropriate for a patient to visit his/her physician, physical therapist, or an outpatient clinic on a continuing
basis for treatment of pain with electrical nerve stimulation. Based on this information, we decided that the
Medicare rules for coverage have not been met.
The file shows that a nutria-pharmaceutical injection was provided. We looked at the file, and Medicare rules.
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. 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 pain management services provided on May 6, 2021.