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

We decided that the Plan does not have to adjust the cost sharing rate to the in-network level for the services you received on September 4, 2019, and September 5, 2019.
You asked the Plan to adjust the services. You say that you were referred by an in-network provider. The Plan denied your request. The Plan says you are responsible for the out-of-network cost share.
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 $55 copayment for physician specialist services. Your contract with the Plan also says that you must pay a 40% coinsurance for diagnostic procedures/tests and CT scans. Review of the file shows that you were provided services by an out-of-network provider on September 4, 2019, and September 5, 2019. You have been asked to pay the out-of-network cost share amount for the services. 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 adjust the cost sharing rate to the in-network level for the services you received on September 4, 2019, and September 5, 2019.
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly MIN assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the heart monitoring services provided on July 23, 2019.You asked the Plan to waive the coinsurance for the heart monitoring services. You say that the testing was not completed and you will not pay this bill The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each out-of-network Medicare-covered other diagnostic test. You have been asked to pay $154.57 which is 20% of the allowed amount for the heart monitoring services. The allowed amount is $772.84. ($772.84 x 20% = $154.57). The heart monitoring services falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows two days of readable data was obtained.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 the heart monitoring services provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on April 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 procedure code 99152 is not supported.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 by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not show the presence of an independent observer to assist in monitoring the enrollee's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on April 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7210) for teeth # 2 and 3 provided on September 16, 2019.You asked the Plan to pay forthe dental services. You say that your dentist advised that this was the best course of treatment.The Plan denied your request. The Plan says surgical extractions are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, surgical extractions are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe surgical extractions (D7210) for teeth # 2 and 3 provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a respiratory assist device.
You asked the Plan to pre-approve a Bi-Level Positive Airway Pressure device (E0471). You say that the enrollee needs a BiPAP device. The Plan denied your request. The Plan says this device is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 a Bi-Level Positive Airway Pressure device (E0471). Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found coverage criteria for BiPAP E0471 are not met. This enrollee has severe complex sleep apnea. The PAP titration study of September 22, 2019 was unsuccessful; adequate settings using E0471 were not found. It was established that the E0470 device was not adequate for this enrollee, because of transition to central events with higher pressures. This enrollee needs another PAP titration study with BiPAP ST, and if that is unsuccessful, ASV titration. There is no clinical note after the PAP titration to justify prescribing the E0471 at this time. It is considered not medically necessary because successful settings were not established. The denial is upheld.
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 Bi-Level Positive Airway Pressure device have not been met. Therefore, we decided that the Plan does not have to pre-approve a BiPAP device (E0471).
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 services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug tests provided on August 21, 2019.
You asked the Plan to pay for the drug tests. You say that these services are not related to hospice care. 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 enrollee's terminal condition.
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 the drug tests provided on August 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had gone out to eat with a friend when you began perspiring and feeling cold. You thought you had food poisoning and the restaurant staff called for an ambulance. You say that you and your friend did not call for the ambulance. The Plan denied your request. The Plan says these services are not a covered benefit.
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 February 3, 2019. 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 services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 95999 provided on February 19, 2019.You asked the Plan to pay forCPT code 95999. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 95999 is not supported.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 record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 95999 provided on February 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on April 18, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. Thismeans that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.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 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 forthe laboratory services provided on July 1, 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 the medical services provided on September 26, 2019 to October 9, 2019 by an out of network (OON) provider.
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 were rendered by a non-contracted 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 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 September 26, 2019 to October 9, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on July 30, 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 must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on July 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services provided on September 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forradiology services. You say that these services were medically necessary,The Plan denied your request. The Plan says no prior authorizationwas obtained for 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approvethe 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 forradiology services provided on September 12, 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 an eye exam provided on April 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an eye exam. You say that you were told the member had Medicare. You say that you were not aware that the member had a community plan. The Plan denied your request. The Plan says no prior authorization was obtained for 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 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 eye exam provided on April 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on May 3, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to payforthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on May 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRestasis eye drops.You asked the Plan to pre-approvethe Restasis eye drops. You say that these drops are medically necessary.The Plan denied your request. The Plan says this is a self-administered drug which cannot be covered by 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 pre-approveRestasis eye drops.Benefits for the Restasis eye dropsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Buzz around scooter for the enrollee.You asked the Plan to pre-approvea Buzzaround scooter. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is not covered for use outside the home.The Plan must follow Medicare rules. Medicare rules say that POV/PWC coded as K0899 will be denied as not reasonable and necessary.We looked at the file and Medicare rules. The Buzzaroundscooter is coded K0899. Based on this information, we decided that Medicare rules for coverage of a Buzzaround scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvea Buzzaround scooter for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed bridge for teeth #'s 6, 7, and 8, bone replacement grafting, core buildups for teeth #'s 6, 8, and 26 and topical application of fluoride varnish.
You asked the Plan to pre-approve the fixed bridge, bone replacement graft, core buildups, and fluoride varnish. You say that you are not able to eat due to your dental issues and this is affecting your health. You cannot afford to pay for this care on your income. The Plan denied your request. The Plan says your dental benefit does not cover the types of services that you require.
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 pre-approve a fixed bridge for teeth #'s 6, 7, and 8, bone replacement grafting, core buildups for teeth #'s 6, 8, and 26 and topical application of fluoride varnish.