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

We decided that the Plan does not have to reimburse you forthe psychotherapy, 45 minutes, provided on August 7, 2019 by the out of network provider.You asked the Plan to reimburse you forthe outpatient mental health services. You say that you have finally found a psychologist that you could relate to. You saythat you felt confident that he could guide you through the feelings and emotions that you were trying to deal with.The Plan denied your request. The Plan says the services you received were not urgent or emergent. The Plan also says authorization was not obtained before the services were provided to the enrollee.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 reimburse you 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 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 reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you forthe psychotherapy, 45 minutes,provided on August 7, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a modality services coded 97012 and 97032 and the manual therapy techniques coded 97140 provided on June 5, 2019.You asked the Plan to pay for the application of a modality services and the manual therapy techniques. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the application of a modality services coded 97012 and 97032 and the manual therapy techniques coded 97140 provided on June 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the disposable supplies and blood pressure monitor provided
by the provider on August 3, 2019.
You asked the Plan to pay for the ambulatory blood pressure monitor and disposable supplies. You say that the
Plan should pay this claim. The Plan denied your request. The Plan says the disposable supplies are not
separately payable and ambulatory blood pressure monitoring is to be performed at least 24 hours.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Procedures should be reported with the CPT code that describes the services performed. You can find this rule
in the Medicare National Correct Coding Initiative Manual, Chapter I(A).
We looked at the file and Medicare rules. In this case, the CPT Code Manual definition of code A4670 is
Automatic blood pressure monitor. This is an equipment code not a procedure code. Disposable supplies are
not payable separately. Based on this information, we decided that Medicare rules for coverage of the
ambulatory blood pressure monitor and disposable supplies have not been met. Therefore, we decided that the
Plan does not have to pay for the ambulance services and supplies provided by the provider on August 3,
2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe infusion pump refill kit provided to the enrollee on January 26, 2019.You asked the Plan to pay forthe refill kit. You say that the claim was not processed correctly.The Plan denied your request. The Plan says the services are bundled into the payment for other related services.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 code the refill kit is a bundled code, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay forthe infusion pump refill kit provided  on January26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by out of network provider.
You asked the Plan to pay for practitioner visit. You say that the facility requested this practitioner to see the enrollee, therefore medical necessity is established. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided on July 31, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 16, 2019 and billed under code 96133.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says based on the Medicare billing guidelines code 96133 is to be "listed separately in addition to code for the primary procedure". The guidelines state providers are to report code 96132 for the first hour and 96133 for each additional hour. The Plan states according to CPT guidelines published by the AMA, "Add-on codes are always performed in addition to the primary service or procedure, and must never be reported as a stand-alone code." The Plan notes there is no claim with CPT 96132 for this date of service.
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 claim submitted has errors preventing payment in regards to code 96133 as there is no billing for code 96132. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 16, 2019 and billed under code 96133.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on April 16, 2018. You asked the Plan to pay forthe office visit. You say that the enrollee provided the incorrect insurance information at the time of service.The Plan denied your request. The Plan says the claim wasnot received within the 365 day timely filing period.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the office visit was not filed until August 23, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay foran office visit (99214) provided on April 16, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone graft (D7953) provided by "the provider" on August 14, 2019.You asked the Plan to pay forthe bone graft. You say that the services should not be billed to you. You say that all of these services are covered by the Plan.The Plan denied your request. The Plan says bone grafts are not a covered service.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 forthe bone graft (D7953) provided by "the provider" on August 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an exploratory laparotomy (49000) and esophagogastroduodenoscopy (43246) provided on May 16, 2019.You asked the Plan to pay for the laparotomy and esophagogastroduodenoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes are not supported as the medical record submitted does not include detailed procedure documentation to support the laparotomy and esophagogastroduodenoscopy.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 49000 is exploratory laparotomy, exploratory celiotomy with or without biopsy(s)(separate procedure).The CPT Code Manual definition of code 43246 is esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube.We asked our coder to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pay for the laparotomy and esophagogastroduodenoscopy. Our reviewer says that CPT codes 49000 and 43246 are not supported by the medical record. Our reviewer found the record submitted consists of an incomplete procedure note. There is insufficient evidence to confirm that 
the procedures in question were performed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the laparotomy and esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for an exploratory laparotomy (49000) and esophagogastroduodenoscopy (43246) provided on May 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 10, 2018 by out of network provider. You asked the Plan to pay for lab test. You say that you believe this claim was filed within the timely filing limit.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan. 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 medical services provided on January 10, 2018 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 10, 2018.
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for lab services. You have been asked to pay a $30 copayment for laboratory services. Laboratory services 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 copayment for laboratory services provided on January 10, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from April 27, 2019 to April 28, 2019.
You asked the Plan to pay for post-stabilization care. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee's condition was stabilized by 1:18m on April 27, 2019 and the enrollee could have been transferred to an in-network facility.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization care. Our reviewer says that this inpatient hospital care does not meet the Medicare criteria for coverage. Our physician reviewer found the medical records document that the enrollee was stable for transfer to an in-network hospital on April 27, 2019 at 1:17pm. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from April 27, 2019 to April 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 29, 2019 by out of network provider.
You asked the Plan to pay for podiatry services. You say that you are in-network with most plans and were unaware that you are out-of-network with this specific health plan. You also say that the enrollee needed this medical care. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring nursing facility is also out-of-network with the Plan.
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 29, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9501) provided on August 1, 2019 through August 8, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because you are in-network with the Plan. The Plan denied your request. The Plan says S9501 is not valid for Medicare purposes.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 code S9501 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, S9501 has a status indicator of "I." This means that S9501 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9501) provided on August 1, 2019 through August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 20, 2019 by out of network 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-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 for the medical services provided on May 20, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2019.You asked the Plan to pay for an extremity study (93971). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services were not authorized because the provider is out-of-network with the plan, the services were not urgent/emergent and there is no network deficiency 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 the medical services provided on July 17, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 4, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly what tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on June 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar spine x-ray rendered to the enrollee on February 11, 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 72114 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 72114 is radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views. We find that CPT code 72114 is not supported in the medical record. Specifically, the records do not identify the number of views performed. 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 lumbar spine x-ray rendered to the enrollee on February 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 28, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare-prohibited action.
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. This means 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 for laboratory testing provided on May 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthoses and the ankle foot orthoses provided on July 18, 2019.You asked the Plan to pay fort he wrist hand orthoses (L3916)and the ankle foot orthoses (L1971). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says the enrollee already had the same orthoses still under reasonable useful lifetime.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 wrist hand orthoses (L3916) received on April 12, 2018, and the ankle foot orthoses (L1971) received on December 20, 2017, from different providers, arestill within the 5-year RUL.The documentation submitted does not show that the orthoses areirreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral orthoses at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare 
coverage criteria for orthoses replacement were not met.Therefore, we decided that the Plan does not have to pay for the wrist hand orthoses and the ankle foot orthoses provided on July 18, 2019