Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe counseling visit to discuss need for lung cancer screening using low dose CT scan services provided on July 9, 2019.You asked the Plan to pay for the counseling visit to discuss need for lung cancer screening using low dose CT scan 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.In this case, the CPT Code Manual definition of code G0296 is counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making).We find that CPT code G0296 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of counseling visit to discuss need for lung cancer screening using low dose CT scan. Based on this information, we decided that Medicare rules for coverage of the counseling visit to discuss need for lung cancer screening using low dose CT scan services have not been met.Therefore, we decided that the Plan does not have to pay forthe counseling visit to discuss need for lung cancer screening using low dose CT scan services provided on July 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the disposable ambulance supplies provided on July 26, 2019.You asked the Plan to pay forthe disposable ambulance supplies (A0382). You say that there were two transports on the same day so the Plan should pay this claim.The Plan denied your request. The Plan says they will pay for both transports but the ambulance supplies are not paid separately.Medicare rules say ambulance supplies are included in the service payment. The Plan follows the same rules. We looked at the file and Medicare rules. Medicare does not pay separately for disposable supplies used during an ambulance service. Based on this information, we decided that Medicare rules for coverage of the disposable ambulance supplies (A0382) have not been met.Therefore, we decided that the Plan does not have to pay forthe first ambulance supplies provided on July 26, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97112 provided from September 23, 2019 to September 26, 2019.
You asked the Plan to pay for the therapeutic procedure. 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. In this case, 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 3 units of CPT code 97112 is not supported in the medical record for each date of service. Specifically, the documentation submitted did not support the units billed. Current Procedural Terminology (CPT) code 97112 represents therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. Minimum of 98 minutes of total time is required to support 7 units of the timed codes on the claimed dates of service. The submitted medical records indicate that total of 83 minutes was spent on the timed codes for each date of service; therefore, the billed service with units and modifier cannot be verified. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97112 provided from September 23, 2019 to September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay for train of four testing (CPT 95999) provided to the enrollee on November 20, 2018.You asked the Planto pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan saystrain of four is considered a bundled procedure, and payment for it is included in the payment for the already-approvedneuromonitoring.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 95999 is "unlisted neurological or neuromuscular diagnostic procedure."We find that CPT code 95999 is not supported in the medical record. Specifically, the payment for this testing is included in the payment for the already-approvedneuromonitoring. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay fortrain of four testing (CPT 95999) provided to the enrollee on November 20, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the presbyopia-correcting intraocular lens (P-C IOL) rendered to you on September 24, 2019.
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 covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia-correcting intraocular lens (P-C IOL) rendered to you on September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from May 1, 2019 to May 19, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled services at an inpatient SNF level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did nothave daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 1, 2019 to May 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora wound pump provided from August 16, 2019 to September 14, 2019.You asked the Plan to waive the coinsurance fora wound pump. You say that the wound pump is overpriced.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 planmust 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 20% coinsurance for durable medical equipment and related supplies. You received a wound pump from August 16, 2019 to September 14, 2019. The allowed amount is $2,852.70 and 20% of that is $570.54. You have been asked to pay the total coinsurance amount of $570.54 for a wound pump. A wound pump falls within thedurable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora wound pump provided from August 16, 2019 to September 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you attempted to get authorization and the services were medically necessary. The Plan denied your request. The Plan says the providing physician is out-of-network. The Plan says that no prior authorization was obtained.
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 has network providers available who can provide 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 office visit provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 minutes of advanced care planning (99497) provided on August 3, 2019.
You asked the Plan to pay for the advanced care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted do not indicate that advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate was performed.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the record. Specifically, the submitted record does not indicate that 30 minutes of advance care planning was rendered. Based on this information, we decided that Medicare rules for coverage of the advanced care planning have not been met. Therefore, we decided that the Plan does not have to pay for 30 minutes of advanced care planning (99497) provided on August 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 3, 2019 to August 23, 2019.You asked the Plan to pay for the skilled nursing services. You say that your admissions department was not aware that this enrollee needed an authorization for their stay with you.The Plan denied your request. The Plan says there were no medical records or insufficient records to make a clinical decision. The Plan also saysthat records were requested several times, but no records were received.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs thatrequired the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 3, 2019 to August 23, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71260). You asked the Plan to pre-approve a CT scan. You say that this is needed to evaluate for disease recurrence.The Plan denied your request. The Plan says that this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 a CT scan. Our reviewer says that the requested CT scan is medically necessary. Our physician reviewer found there is no consensus guidelines on frequency and modality of post treatment imaging for the enrollee's condition. Deference should be made to the treating provider in absence of guidelines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan have not been met.Therefore, we decided that the Plan has to pre-approvea computed tomography (CT) scan of the thorax (71260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tracheostomy (31600) provided on September 4, 2019.
You asked the Plan to pay for the Tracheostomy. You say that the services were medically necessary and the presence of an assistant surgeon reduces the risk for complications. The Plan denied your request. The Plan says the services of an assistant surgeon, co-surgeon or surgical team are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 31600. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the Tracheostomy have not been met. Therefore, we decided that the Plan does not have to pay for a Tracheostomy (31600) provided on September 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Air Ambulance transport provided on August 11, 2019.
You asked the Plan to pay for the air ambulance service. You say that the transport was medically necessary. The Plan denied your request. The Plan says the sending facility was able to provide the services needed by the enrollee. The transport was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 the air ambulance service. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there is no evidence that the sending facility was unable to provide the services required by the enrollee. The interfacility transport appears to have occurred entirely at the bequest of the enrollee. Such transports are not considered medically necessary, reasonable, or covered. 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 air ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for Air Ambulance transport provided on August 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 23, 2019 to September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing care (99308). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is not in-network and there is no authorization on file.
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 has network providers available who can provide 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 medical services provided on January 23, 2019 to September 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic visit provided September 12, 2019.
You asked the Plan to waive the copayment for the chiropractic visit. You say that the chiropractic manipulation is helping your back pain and the service should not be denied. The Plan denied your request. The Plan says the chiropractic service is not denied and the claim was reprocessed and applied the $20 in-network copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment, after the deductible, per in-network Medicare-covered visit. You have been asked to pay a $20 copayment for the chiropractic visit. The chiropractic visit falls within the "Chiropractic services" benefit category. The record shows you had met the in-network deductible. Therefore, the in-network copayment was applied.
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 chiropractic visit provided on September 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility careprovidedon July 3, 2019 and September 4, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decidedthat the Plan does not have to pay for subsequent nursing facility care provided on July 3, 2019 and September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on September 18, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the record does not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage
of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on October 16, 2019.
You asked the Plan to pay for the orthosis. You say that The Plan denied your request. The Plan says that documentation submitted did not include a valid physician order, proof of delivery, or a delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on October 16, 2019.