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

We decided that the Plan does not have to pay for the laboratory services (G0452) provided on September 15,
2021.
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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services (G0452) provided on September 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on July 18, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request.
The Plan says the Medicare ambulance benefit is a transportation benefit and without transport 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 July 18, 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 ambulance response and treatment, no transport
(A0998) provided on July 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.
You asked the Plan to pre-approve Xiidra. The Plan denied your request. The Plan says this is not a covered benefit.
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 Xiidra.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81201, 81295, 81298, 81317, 81403, 81404,
81405, 81406) provided August 5, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that to report a Comprehensive Genomic Profile
(CGP) screening service providers should use 1 unit only of CPT code 81479 for the entire bundled multi-test
panel.
We looked at the file and Medicare rules. Multiple unbundled codes were billed instead of a single unit of
81479. Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (81201, 81295, 81298,
81317, 81403, 81404, 81405, 81406) provided August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient wound care services provided on May 18, 2021.
You asked the Plan to waive the copayment for the outpatient wound care services. You say that the services should be 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 $250 copayment for Outpatient hospital services.
You have been asked to pay a $250 copayment for outpatient wound care services. Outpatient wound care services fall within the Outpatient hospital 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 outpatient wound care services provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 16, 2021.
You asked the Plan to pay for the services. You say that you would like reconsideration based on the records submitted The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: 80157: Carbamazepine; free 80159: Clozapine 80162: Digoxin; total 80173: Haloperidol 80177: Levetiracetam 80201: Topiramate
We asked our coder 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found per the guidelines for these codes, the material for examination is whole blood, serum plasma, or cerebrospinal fluid. The laboratory documents urine, so the codes cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health therapy services.
You asked the Plan to pre-approve the continuation of home health therapy services. You say that the requested continuation of home health therapy services is medically necessary. The Plan denied your request. The Plan says the requested continuation of home health therapy services is not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 the continuation of home health therapy services. Our reviewer says that the requested continuation of home health therapy services is not medically necessary. Our physician reviewer found the records do not show that skilled occupational or speech therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function
and/or prevent deterioration beyond what was approved by the health plan. The enrollee is ambulating at a high level and the documentation does not reveal that leaving the home is a taxing effort currently therefore he is no longer considered homebound. The enrollee does not require ongoing skilled speech therapy (ST) for his cognitive communication needs. He does not require ongoing occupational therapy (OT) for his functional deficits. Safety precautions and a home exercise program have been reviewed with the enrollee and his functional level no longer requires ongoing skilled OT beyond what was approved by the health plan. The enrollee can transition to an independent home program for ST and OT. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of home health therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of home health therapy services.
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 SNF care is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of SNF care.

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 you do not require skilled nursing or therapy services on a daily basis in a skilled nursing facility 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 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99282) provided
on September 6, 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for the emergency care 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 emergency room visit (99282) provided on
September 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the documentation provided there is no evidence that you require services
that are not currently available at the present setting where you are receiving care. You can remain at the
current setting until such time no acute services are required. You can then be transferred/discharged to a lower
level of care for any ongoing long term care needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on March 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the documentation submitted did not support that the laboratory services were provided with blood sampling. Blood specimen collection is by venipuncture; however, the lab requisition states a urine specimen was collected; therefore, the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle-skin grafts (15734) provided on April 27, 2021.
You asked the Plan to pay for the muscle-skin grafts (15734). You say that additional funds are due for CPT
code 15734 not being paid. You say that the operative report supports the claim and should be reprocessed for
additional funds. The Plan denied your request. The Plan says procedure code 15734 is not supported by the
medical records submitted.
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 15734 is muscle, myocutaneous, or fasciocutaneous flap;
trunk.
We asked our coder 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 the muscle-skin grafts (15734). Our reviewer says that the
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that
the operative report does not include enough detailed documentation to confirm this procedure.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the muscle-skin grafts (15734) have not been met. Therefore, we decided that
the Plan does not have to pay for the muscle-skin grafts (15734) provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient hospital care rendered from
August 5, 2021, to August 9, 2021.
You asked the Plan to reduce the copayment for inpatient hospital care. You say that you should not be charged
for a coronavirus (Covid-19) test. You also say that you were hospitalized on August 6, 2021, to August 8,
2021, and you were not hospitalized on August 5, 2021. The Plan denied your request. The Plan says you were
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 $175
copayment each day for days 1 to 7 for Medicare-covered hospital care.
You have been asked to pay a total of $700 for 4 days of inpatient hospital care ($175 copayment x 4 days =
$700). The record shows that there were inpatient admissions on August 5, 2021. 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 inpatient hospital care rendered from August 5, 2021, to August 9, 2021.
Your complaint about the potentially incorrect billing from the hospital 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 pay for an outpatient mental health visit (99214, 96127)  provided on March 9, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an outpatient mental health visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says these services were not authorized. The Plan also says that the rendering provider is a non-participating provider and there is no referring provider in these 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an outpatient mental health visit (99214, 96127)  provided on March 9, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services and drugs/vitamins provided on July 29, 2021.
You asked the Plan to pay for therapeutic services and drugs. You say that you are appealing with supporting records. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State Law. Medicare rules state that all claims for compounded drugs must be submitted using a compounded drug not otherwise classified code.
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 be paid. Based on this information, we decided that Medicare rules for coverage of therapeutic services and drugs have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic services and drugs/vitamins provided on July 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Eliquis.
Benefits for Eliquis 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81295, 81298, 81317, 81432 and 81479 provided on June 19, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 81295 and 81298 are column II codes to column I code 81432. This claim has not been billed with an appropriate modifier to bypass the edit.  We find that CPT codes 81317, 81432, and 81479 are not supported in the medical record. Specifically, these services should use only one unit of code 81479 to describe the entire panel provided. Review of the file does not support that only one CPT code was billed for these services rendered.  Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81295, 81298, 81317, 81432 and 81479 provided on June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) rendered by the
out-of-network (OON) provider on September 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
A telehealth service was provided to the enrollee in this case; however, the provider is not a network provider
with the Plan. The Plan contract states that if an enrollee chooses to get a covered service by telehealth, they
must use a network provider. The Plan did not pre-approve the service at issue. We found no exception that
would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the
psychiatric diagnostic evaluation (90792) rendered by the out-of-network (OON) provider on
September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lead wires (A4557), provided on September 3, 2021.
You asked the Plan to pay for the lead wires. You say that the item is medically necessary. The Plan denied your request. The Plan says this service is included in another service provided at the same time or within a one-year period.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the member purchased a TENS unit within the past year. The TENS unit purchased included lead wires and it is not medically necessary for additional lead wires within a year of purchase. Therefore, we decided that the Plan does not have to pay for the lead wires (A4557), provided on
September 3, 2021.