Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the excision of benign lesion (D7411) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided on March 1, 2021 by a Medicare opt out provider.  

You asked the Plan to pay for the excision of benign lesion and local anesthesia. You say that this procedure was not a dental procedure. The Plan denied your request. The Plan says the treating provider had opted out of the Medicare program. The Plan also says that you were advised that your insurance was not accepted and that the provider had opted out prior to these services being rendered.  

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 covered when they are received by a provider who has opted out of Medicare. The record also shows that you signed an opt out private contract with the treating provider acknowledging that you were informed that the treating provider had opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the excision of benign lesion (D7411) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided on March 1, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aid and related services (V5261, V5267) provided on July 13, 2021.  

You asked the Plan to pay for hearing aid services. You say that these services are necessary and should be covered. The Plan denied your request. The Plan says hearing aids and routine hearing services are not covered by Medicare or by your Plan under any condition.  

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services.   

Though hearing aid services may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for the hearing aid and related services (V5261, V5267) 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 cataract surgery (66984) provided on April 26, 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 $100 copayment for Medicare covered services at an ambulatory surgical center.     

You have been asked to pay a $100 copayment for the Medicare covered surgery provided at the ambulatory surgical center. 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 cataract surgery (66984) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a clinic visit (G0463) provided on July 28, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a clinic visit. You say that this is supported in the records. 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 a clinic visit (G0463) provided on July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on September 16, 2021  You asked the Plan to pay for the complete series of intraoral x-rays. You say that you were told that an exam, cleaning, and x-rays would be covered by your plan. The Plan denied your request. The Plan says this is not a covered service.  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. The only type of x-ray that is covered by your plan is horizontal bitewing x-ray images. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on September 16, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subcutaneous or intramuscular (96372), the Physical performance test or measurement (97750), the therapeutic procedure (97112), the Unclassified drugs (J3490), the Thiamine injection (J3411), the Pyridoxine injection (J3415), the Compounded drug, not otherwise classified (J7999), the application of a modality (97016), and an unlisted therapeutic procedure (97139) provided on September 9, 2021.  You asked the Plan to pay for codes 96372, 97750, 97112, J3490, J3411, J3415, J7999, 97016, and 97139. 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 Medicare Part B pays for outpatient physical therapy services by an NP or PA only when that NP/PA may perform physical therapy services under State law. The 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 a review of the file and publicly available records, we find that the physical therapy services at issue were rendered by a 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 payable as billed, the drug administration code, 96372, also cannot be paid. 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 the subcutaneous or intramuscular (96372), the Physical performance test or measurement (97750), the therapeutic procedure (97112), the Unclassified drugs (J3490), the Thiamine injection (J3411), the Pyridoxine injection (J3415), the Compounded drug, not otherwise classified (J7999), the application of a modality (97016), and an unlisted therapeutic procedure (97139) provided on September 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided on July 21, 2021 to August 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says services rendered by an out of network provider are not covered. The Plan also says that the enrollee's primary care physician (PCP) did not refer them for the services.  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 did not pre-approve the item/service at issue. Additionally, the Plan confirmed that the referring provider in this case is not your primary care physician. 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 the home health services provided on July 21, 2021 to August 19, 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 (87496, 87498, 87798, 87486, 87541, 87581, and 87640) provided on August 5, 2020.  You asked the Plan to pay for the laboratory services. 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.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 81. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 31. Therefore, we decided that the Plan does not have to pay for the laboratory services (87496, 87498, 87798, 87486, 87541, 87581, and 87640) provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the therapeutic exercises (97110) and neuromuscular education (97112) provided on September 17, 2021.  You asked the Plan to pay for the physical therapy services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says that the records show that the requested service was not furnished.  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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.  We find that CPT codes 97100 and 97112 are supported in the medical record. Specifically, contrary to the Plan's assertion that there is no evidence these services were furnished there is a clear daily note submitted for date of service September 17, 2021, that includes both 97100 and 97112 as being performed. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have been met. Therefore, we decided that the Plan has to pay for the therapeutic exercises (97110) and neuromuscular education (97112) provided on September 17, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider on May 21, 2020, to June 3, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.    You have been asked to pay a $350 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,750 ($350 x 5 days = $1,750). You have been charged at an in-network rate; therefore, the correct copayment has been applied. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider on May 21, 2020, to June 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0425, A0428) provided on June 9, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that this service was necessary, and the enrollee was not consulted regarding this service or any related copayments. The Plan denied your request. The Plan says this claim was processed in accordance with the enrollee's contract. Ambulance services require a $250 copayment per trip.  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 $250 copayment for ambulance services.    The enrollee has been asked to pay a $250 copayment for the ambulance transportation. 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 ambulance transportation services (A0425, A0428) provided on June 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 26, 2021, to March 4, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration because this claim was billed appropriately. The Plan denied your request. The Plan says the RAP was submitted outside the CMS timeframe.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that this episode of care began on February 26, 2021. The record indicates that a RAP was not submitted until August 27, 2021. This is outside of the CMS allowable timeframe. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 26, 2021, to March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 21, 2021 to February 25, 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 submitted records do not support the billing of principal diagnosis A41.51 and sequence diagnosis N10.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis A41.51 (sepsis due to e. coli) and sequence diagnosis code N10 (acute pyelonephritis). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the submitted records do not support the billing of principal diagnosis A41.51 and sequence diagnosis N10. Our physician reviewer found the records support an admission for further evaluation and treatment of acute pyelonephritis in a patient with a past medical history to include chronic urinary tract infections, chronic back pain and hypertension. While sepsis is documented, other medical record documentation is incomplete regarding this condition. The nephrology consultation consistently indicates acute kidney injury versus chronic kidney disease and a renal ultrasound showed the right kidney was smaller than the left. Initial labs showed acute kidney injury. The records do not support the billing of principal diagnosis A41.51 and sequence diagnosis N10.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from February 21, 2021 to February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330), 2 extractions (D7210), and bone replacement graft (D4263) provided on August 8, 2021 by the out of network dentist.  You asked the Plan to reimburse you for the dental services. You say that you assumed the extractions would be covered. You also say that extractions are listed as coverage in your booklet. The Plan denied your request. The Plan says dental 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 and panoramic x-ray, and extraction are listed as covered, dental services received out of network are not among those covered under this benefit. Additionally, bone replacement graft is not a covered service regardless of the provider's network status. Therefore, we decided that the Plan does not have to reimburse you for the panoramic x-ray (D0330), 2 extractions (D7210), and bone replacement graft (D4263) provided on August 8, 2021 by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit for a coronavirus test provided on August 10, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that you only went in for a coronavirus test and should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged 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 $30 copayment for each urgently needed service.     You have been asked to pay a $30 copayment for the urgent care visit. The urgent care visit falls within the Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit for a coronavirus test provided on August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray (73502) provided in an outpatient hospital on March 18, 2021. 

You asked the Plan to waive the copayment for an x-ray. You say that you were not told this provider was out-of-network. The Plan denied your request. The Plan says this copayment applies regardless of network status.  

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 $105 copayment for diagnostic procedures and tests provided in an outpatient hospital.   

You have been asked to pay a $84.55 copayment for an x-ray because the allowed amount for this service is less than the copayment listed in your contract with the Plan. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray (73502) provided in an outpatient hospital on March 18, 2021.