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

We decided that the Plan does not have to pay for the self-administered drugs provided from June 3, 2021, through June 4, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you do not take these at home and the charge is astronomical. The Plan denied your request. The Plan says Medicare Part B does not cover drugs that are self-administered by the patient.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from June 3, 2021, through June 4, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies (95908) provided on March 1, 2021.

You asked the Plan to pay for the nerve conduction studies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says records show that you have billed and been allowed 95864 so separate charges for 95908 are not eligible for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95908 is a column II code to column I code 95864. Medicare does not allow for a modifier exception for these codes, so CPT code 95908 is not eligible for separate payment. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies (95908) provided on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on June 30, 2021.

You asked the Plan to reduce the copayment for the specialist office visit. You say that the services did not take place on this date of 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 $50 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted by Medicare rules). 

You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a consultation for abdominal pain.

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 reduce the copayment for the specialist office visit provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a guided tissue regeneration (D4266), and a bone graft (D6104) provided by a contracted provider on August 3, 2021.
You asked the Plan to pay for a guided tissue regeneration and a bone graft. You say that you would like the Plan to pay for this dental work. The Plan denied your request. The Plan says the dental services provided are not a covered benefit.
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 a guided tissue regeneration (D4266), and a bone graft (D6104) provided by a contracted provider on August 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services rendered on May 31, 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. The rules say that a clinical psychologist must have a referral and consult
from the beneficiary's primary care physician.
We looked at the file and Medicare rules. There is no documentation of a referral and consult from the
enrollee's primary care physician. 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
psychotherapy services rendered on May 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and filling (D2330) provided from May 19, 2021, to May 26, 2021.
You asked the Plan to pay for the dental services. You say that the plan information was not properly taken into consideration. You say that there is no mention of in or out of network benefits. You also say that the services
should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services received out of network are not covered.
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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), and filling (D2330) provided from May 19, 2021, to May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve physical therapy services to be provided by an OON provider. You say that
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are
able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist provider office visit (99214) and an ultrasound of the heart (93306) provided on May 1, 2021.
You asked the Plan to waive the copayments for an office visit and an ultrasound of the heart. You say that you being charged an incorrect copayment for the services at issue. The Plan denied your request. The Plan says the correct copayments were 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 $110 copayment for Medicare-covered diagnostic radiology services and a $45 copayment for specialist physician services.
You have been asked to pay a $110 copayment for an ultrasound of the heart and a $45 copayment for an office visit. An ultrasound of the heart falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category and an office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amounts 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 copayments for a specialist provider office visit (99214) and an ultrasound of the heart (93306) provided on May 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (45385) provided August 3, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you expected this to be a screening colonoscopy and would like an exception. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for ambulatory surgical center visits.
You have been asked to pay a $175 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient surgery, including 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 colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique (45385) provided August 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neuromonitoring rendered on April 16, 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 separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes G0453 (continuous intraoperative neuromonitoring) and 95940 (continuous intraoperative neurophysiology monitoring in the operating room). Code G0453 is a column II code with a modifier indicator of 1 when billed with column I code 95940. Code G0453 was not billed with an appropriate modifier to allow for separate payment.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.
The rules say that procedure codes with a status indicator of P are bundled/excluded codes. The rules say that procedure codes with a status indicator of X are statutorily excluded.
Billed procedure code A4556 (electrodes, pair) has a status indicator of P and no separate Medicare payment. Code A4215 (needle, sterile) has a status indicator of X and is statutorily excluded from Medicare payment.
Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neuromonitoring rendered on April 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subcutaneous and intramuscular injection (96372) unclassified drugs (J3490) unlisted therapeutic procedure (97139) therapeutic procedure, neuromuscular reeducation (97112) provided June 24, 2021.

You asked the Plan to pay for the outpatient services. You say that please review the documents and reprocess this claim for payment. The Plan denied your request. The Plan says the Sanexas machine has not shown to be beneficial and vitamin injections have not shown to be of any clinical utility in the management of neuropathic pain.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 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. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for subcutaneous and intramuscular injection (96372) unclassified drugs (J3490) unlisted therapeutic procedure (97139) therapeutic procedure, neuromuscular reeducation (97112) provided June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82607, 80053, 84443, 80306, 85025, 87086) rendered by the out-of-network (OON) provider on August 23, 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 (82607, 80053, 84443, 80306, 85025, 87086) rendered by
the out-of-network (OON) provider on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (K0606), provided on July 8, 2021.

You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that the item should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment (DME) and related supplies. 

You have been asked to pay a 20% coinsurance for the automatic external defibrillator. This item falls within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (K0606), provided on July 8, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is not yet shown to have reached a plateau in function. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 Guardian Sensor 3 provided on April 26, 20021, through October 24, 2021.
You asked the Plan to pay for Guardian Sensor 3. You say that the item is medically necessary. The Plan denied your request. The Plan says you are using the Guardian Sensor 3 in combination with the Medtronic 670G insulin pump. Therefore, the Guardian Sensor 3 is classified as "non-therapeutic" by Medicare and is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that effective for claims with dates of service on or after January 12, 2017, Medicare covers therapeutic CGM devices under the DME benefit. CGM devices covered by Medicare are defined in CMS Ruling 1682R as therapeutic CGM. CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Guardian Sensor 3 have not been met. Therefore, we decided that the Plan does not have to pay for the Guardian Sensor 3 provided on April 26, 20021, through October 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care office visit (99203) provided on July 21, 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 $65 copayment for an urgently needed care visit rendered by an in-network or out-of-network provider.
You have been asked to pay a $65 copayment for the urgent care 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 urgent care office visit (99203) provided on July 21, 2021.