Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 26, 2021.  You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the subcutaneous tissue debridement (11042) provided on August 4, 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 $325 copayment for each in-network Medicare-covered outpatient hospital facility visit for outpatient surgery.    You have been asked to pay a $325 copayment for the Medicare-covered outpatient surgery provided at an  in-network outpatient hospital facility. 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 subcutaneous tissue debridement (11042) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (80299, 80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on May 26, 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 (80299, 80307, 82542, 83789, G0480) rendered by the out-of-network (OON) provider on May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ibrance.  You asked the Plan to pre-approve Ibrance. You say that the drug is medically necessary. The Plan denied your request. The Plan says Ibrance is a self-administered drug.   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 pre-approve Ibrance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for panoramic x-ray (D0330) and 2D oral/facial photographic image (D0350) provided on August 17, 2021.  You asked the Plan to pay for the dental services. You say that you had to switch to a new dentist because your previous dentist did not take your insurance. They did not want to use your old x-rays and asked them to make sure the services would be covered before they were performed. The Plan denied your request. The Plan says they have agreed to re-process and cover the comprehensive oral exam and the complete series of x-rays; however, your benefit does not cover 2D oral/facial photographic images under any condition, and only one complete series of x-rays or panoramic x-ray may be covered every five years. 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. The Plan does not cover services which are not listed in the dental benefits chart section of the contract. The Plan can cover one full mouth complete x-ray series or one panoramic x-ray every five years.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 2D oral/facial photographic images are not among those covered under this benefit. In addition, only one complete series of x-rays or panoramic x-ray may be covered every five years. The Plan provided documentation that they have agreed to pay for the complete series of x-rays provided on the date in question. The panoramic x-ray exceeds the frequency limitation of these services. Therefore, we decided that the Plan does not have to pay for panoramic x-ray (D0330) and 2D oral/facial photographic image (D0350) provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the medical dressings provided on August 12, 2021, and August 26, 2021.  You asked the Plan to waive the coinsurance for the medical dressings. You say that you were not informed there would be a charge for the supplies. You say this should be covered under the care following the operation in the hospital. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for medical supplies.   The enrollee has been asked to pay $121.57 which is 20% of the allowed amounts for the medical dressings. The medical dressings fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.  Date of Service Service Allowed Amount Coinsurance Member Liability August 12, 2021 Medical dressings $131.90 20% $26.38 August 26, 2021 Medical dressings $367.05 20% $73.41 August 26, 2021 Medical dressings $108.90 20% $21.78 Total    $121.57  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 coinsurance for the medical dressings provided on August 12, 2021, and August 26, 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 enrollee needs to start lymphedema therapy. Home health and skilled nursing do not have trained nurses to do the lymphedema therapy. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.  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 that on review of the available records, the enrollee is currently medically stable and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehabilitation nursing needs noted in the record. At the current level of function, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. An IRF admission is not medically necessary based on medical stability and lack of rehabilitation nursing needs. The documentation does not support the necessity for admission to an IRF. The enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting.  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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 13, 2021.  You asked the Plan to pay for the limited oral exam. You say that you would like this service 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 limited oral evaluation - problem focused (D0140) provided September 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on May 28, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lacrimal duct implant rendered on September 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 separately payable.  The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code A4263 (permanent, long term, non-dissolvable lacrimal duct implant, each) has a status indicator of B an no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the lacrimal duct implant rendered on September 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, TENS, vasopneumatic device, Prolotherapy and vitamin injections provided on August 25, 2021.  You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, TENS, vasopneumatic device, Prolotherapy and vitamin injections. You say that the medical records support the medical necessity for the services. The Plan denied your request. The Plan says Medicare does not cover Prolotherapy. Prolotherapy is believed to stimulate the body's ability to heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative processes. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered, which is like acupuncture. The TENS device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic/vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. As non-covered services they are not a benefit when ordered by either a contracted or a non-contracted provider in any plan design.  The Plan must follow Medicare rules. Medicare rules say that that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law.  The rules say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes.   We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot. Medicare rules say claims for Prolotherapy must not be reported with the trigger point codes or other injection codes. Therefore, we decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, TENS, vasopneumatic device, Prolotherapy and vitamin injections provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (83789, 80307, G0480) provided on August 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that the provider sent the specimen to an unaffiliated laboratory and services were rendered by this provider. You also say that the referring physician is a contracted provider. You also say that you want the Plan to review the documents and to reprocess the claim according to the benefits of the Plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.   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 drug testing (83789, 80307, G0480) provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-sharing for an x-ray of the lower leg (73590) provided on February 7, 2020.   You asked the Plan to waive the cost-sharing for the x-ray. You say that you don't understand why the x-ray isn't covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $50 copayment for Outpatient diagnostic tests and therapeutic services and supplies.     You have been asked to pay a $24.45 copayment for an x-ray, which is less than the $50 stated in the Plan's contract. The record indicates that these services were performed in an independent diagnostic testing facility, which means that the higher copayment would apply. X-rays fall 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 cost-sharing for an x-ray of the lower leg (73590) provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) physical performance test or measurement (97750) therapeutic, prophylactic, or diagnostic injection (specify substance or drug (96372) neuromuscular reeducation (97112) unclassified drugs (J3490) thiamine injection (J3411) pyridoxine injection (J3415) compounded drug, not otherwise classified (J7999) vasopneumatic device (97016) provided August 24, 2021.  You asked the Plan to pay for the outpatient services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered under the Plan benefits.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot 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 electrical stimulation (G0283) physical performance test or measurement (97750) therapeutic, prophylactic, or diagnostic injection (specify substance or drug (96372) neuromuscular reeducation (97112) unclassified drugs (J3490) thiamine injection (J3411) pyridoxine injection (J3415) compounded drug, not otherwise classified (J7999) vasopneumatic device (97016) provided August 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on March 4, 2021.  You asked the Plan to pay for the ambulance response without transport. You say that you were perfectly fine after services were provided in the home and you did not need to be transported to the hospital. You feel these services should be covered, and the paramedics did not use all the equipment listed on the claim. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When there is no transportation provided, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on March 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.      Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment without transport (A0998) provided on March 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Orencia Clickject.  You asked the Plan to pre-approve Orencia Clickject. You say that the drug is medically necessary. The Plan denied your request. The Plan says Orencia Clickject injection is on the self-administered drug list and is excluded from coverage under 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 pre-approve Orencia Clickject.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a resin-based composite (D2331) provided by a participating provider on July 29, 2021.  You asked the Plan to waive the coinsurance for a resin-based composite. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct coinsurance 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 50% coinsurance for dental services/comprehensive dental services.   You have been asked to pay a 50% coinsurance of the allowed amount for a resin-based composite. The total allowed amount is $84. The total amount you are being asked to pay is $42 ($84 x 50% = $42). A resin-based composite falls within the dental services/comprehensive dental 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 coinsurance for a resin-based composite (D2331) provided by a participating provider on July 29, 2021.