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

 We decided that the Plan does not have to pay for prothrombin time testing (85610) provided on June 14, 2021.  You asked the Plan to pay for prothrombin time testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of prothrombin time testing have not been met. Therefore, we decided that the Plan does not have to pay for prothrombin time testing (85610) provided on June 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 14 to July 30, 2021, by an out-of-network provider.  You asked the Plan to pay for psychotherapy services. You say that the provider offered you a complimentary wellness exam at no cost. The Plan denied your request. The Plan says rules for payment for out-of-network care 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 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 psychotherapy services provided on July 14 to July 30, 2021, by an out-of-network provider.   Your complaint about receiving erroneous or incomplete information from the provider 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for spectral doppler echocardiography provided on October 20, 2021.  You asked the Plan to waive the copayment for spectral doppler echocardiography. You say that this test was done due to you having had the coronavirus. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $250 copayment for diagnostic imaging.  You received spectral doppler echocardiography on October 20, 2021. The record shows that this service does not qualify for the coronavirus waiver. Therefore, you are responsible to pay the $250 copayment.      You have been asked to pay a $250 copayment for spectral doppler echocardiography. Spectral doppler echocardiography falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for spectral doppler echocardiography provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine rendered on September 30, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on September 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on June 17, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee was a then, 80-year-old female with a diagnosis of cellulitis of the right lower leg. The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on June 17, 2021. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on June 17, 2021. The documentation did not support that the ambulance transport on June 17, 2021 was medically reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the facet joint injections (64494) provided on May 10, 2021.  You asked the Plan to pay for the facet joint injections (64494). You say that separate procedures were performed, and the reports are attached for review. You say that the claim should be reprocessed. The Plan denied your request. The Plan says CPT code 64494 was not billed properly.  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 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. CPT code 64494 should have been billed once with the appropriate modifier to indicate separate procedures. Based on this information, we decided that Medicare rules for coverage of the facet joint injections (64494) have not been met. Therefore, we decided that the Plan does not have to pay for the facet joint injections (64494) provided on May 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 additional home health skilled nursing visits.  You asked the Plan to pre-approve additional home health services. You say that additional home health services are medically necessary. The Plan denied your request. The Plan says there is no medical need for the home health services beyond what has been approved.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 additional home health services. Our reviewer says that the requested additional home health services are not medically reasonable and necessary. Our physician reviewer found that you are receiving wound care to a small left ischial wound. You have caregivers who are able to provide wound care in the absence of a nurse. Additional skilled nursing needs are not documented. As such, the requested frequency of home health skilled nursing services is not shown to be medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) neuromuscular reeducation (97112) vasopneumatic device (97016) subcutaneous and intramuscular injection (96372) unclassified drug (J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) compounded drug, not otherwise classified (J7999) provided on August 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says these services are not Medicare covered benefits. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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. Review of the file and publicly available records, we also 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. 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 electrical stimulation (G0283) neuromuscular reeducation (97112) vasopneumatic device (97016) subcutaneous and intramuscular injection (96372) unclassified drug (J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) compounded drug, not otherwise classified (J7999) provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drug provided in an outpatient setting on August 5, 2021.  You asked the Plan to pay for the self-administered drug. You say that the correspondence you received states that you self-medicated. You say that you went in to get a computed tomography (CT) scan. You also say that you were there for 11 hours. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.  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 drug provided in an outpatient setting on August 5, 2021.   Benefits for the self-administered drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and removal of impacted ear wax (69210) provided on March 3, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and related services. You say that this service was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 the office visit (99213) and removal of impacted ear wax (69210) provided on March 3, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the pelvic and transvaginal ultrasounds (76830, 76856) provided on July 7, 2021.  You asked the Plan to waive the deductible for the ultrasounds. You say that you do not understand why these services are not covered. The Plan denied your request. The Plan says these services are covered, and the Plan's allowed amount for this service (discounted rate) has been applied. However, your $500 annual deductible applies to outpatient radiological diagnostic services such as ultrasounds. You had not met your deductible prior to the date in question, and the amount you owe for the ultrasounds is applied to your deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 which applies to outpatient radiological diagnostic services.   The item or service you asked the Plan to waive the deductible for falls within the outpatient radiological diagnostic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 which applies to outpatient radiological diagnostic services. This cost sharing is a contractual obligation that had not been met at the time the ultrasounds was received on July 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the pelvic and transvaginal ultrasounds (76830, 76856) provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cone beam three-dimensional (3D) image (D0360) provided on July 20, 2021.  You asked the Plan to pay for the cone beam 3D image. You say that this x-ray was absolutely necessary as the bacteria would not have shown up on a regular x-ray. You also say that many times this x-ray is done as a precaution but in your case, it was a necessity, and you feel it should be covered by the Plan. The Plan denied your request. The Plan says this procedure is not a listed benefit under your plan.  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 cone beam three-dimensional (3D) image (D0360) provided on July 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on October 11, 2021.  You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that the test was done due to your previous diagnosis of the coronavirus so you should not owe the copayment. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $250 copayment for myocardial nuclear perfusion imaging.     You have been asked to pay a $250 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for myocardial perfusion imaging provided on October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing home health care services.  You asked the Plan to pre-approve skilled nursing home health care services. You say that home health care is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 skilled nursing home health care services. Our reviewer says that home health care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). The enrollee does not have documented skilled therapy needs.  As such, the requested, ongoing, home health services are not shown to be medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing home health care services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing home health care services.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on July 1, 2021.  You asked the Plan to pay for the IV tubing and infection control supplies. You say that you would like these services reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not eligible 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.  We looked at the file and Medicare rules. In this case, these codes both have a Status Code of "I" under the Physician Schedule indicating that they are not valid for Medicare purposes. Specifically, Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the IV tubing and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing (S1015) and infection control supplies (S8301) provided on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 15, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, a preventive/screening vitamin assay, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device provided on August 3, 2021.  You asked the Plan to pay for the CPAP. You say that your previous CPAP was recalled. The Plan denied your request. The Plan says that the provider must be eligible to participate in Medicare.  The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program.  The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device provided on August 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on January 20, 2021.  You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code to bill for the services rendered.  The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to the services of a physician/NPP also must meet all incident-to requirements.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Specifically, the record shows that this claim was billed by a nurse practitioner and the services were rendered by an occupational therapist. There is no evidence that the nurse practitioner directly supervised the therapy services. The incident to criteria have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on July 10, 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 70544 (MRA head) and 70551 (magnetic resonance imaging of the brain). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on July 10, 2021.