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

We decided that the Plan does not have to pay for the therapeutic repetitive transcranial magnetic stimulation
(TMS) treatment (90868) provided on December 2, 2019.
You asked the Plan to pay for the therapeutic repetitive (TMS) treatment. You say that the therapeutic
repetitive (TMS) treatment provided was medically necessary. The Plan denied your request. The Plan says the
enrollee did not meet criteria for the provided therapeutic repetitive (TMS) treatment.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. The file did not include documentation showing that the above LCD
criteria was met in order to demonstrate that the therapeutic repetitive (TMS) treatment was medical ly
appropriate. Based on this information, we decided that Medicare rules for coverage of the therapeutic
repetitive (TMS) treatment have not been met. Therefore, we decided that the Plan does not have to pay for the
therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (90868) provided on December 2,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on January 3, 2020, to March 2, 2020 by an out of network provider.
You asked the Plan to pay for the oxygen services. You say that you would like to be paid until the enrollee changes providers. The Plan denied your request. The Plan says you did not request 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the oxygen services provided on January 3, 2020, to March 2, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 23, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services
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
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 physician's services provided on July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on August 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.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 forlab work provided on August 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 14, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there was
no referring provider.
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 physician services provided on January 14, 2020
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided July 22, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says a valid diagnosis code was not 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. We find that CPT code A0425 & A0427 is not supported in the medical record. Specifically, an "unspecified" diagnosis code was billed. Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code. Sufficient information was provided to assign a specific code. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided July 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forskilled nursing facility services provided from July 2, 2020, to July 21, 2020.You asked the Plan to reimburse you forthe skilled nursing facility services. You say that you would not have stayed longer but you did not get the physical therapy you needed.The Plan denied your request. The Plan says you no longer met the skilled nursing level of care criteria.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. 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 reimburse you for the skilled nursing facility services. Our reviewer says that daily skilled services werenot necessary. Our physician reviewer found regarding rehabilitation services, youreceived PT and OT in the SNF. By the dates in question upon evaluation, you were at a contact guard assist level with functional mobility including gait to 100 feet with a rolling walker. Yourequired varying assist with ADLs. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs.You didnot require skilled nursing or therapy services on a daily basis. You didnot meet severity of illness or intensity of service criteria for an inpatient 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 the skilled nursing facility services have not been met.Therefore, we decided that the Plan does not have to reimburse you forskilled nursing facility services provided from July 2, 2020, to July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77065)
provided October 23, 2020.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that the coapyment
should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for basic imaging services.
You have been asked to pay a $40 copayment for the diagnostic mammogram. The diagnostic mammogram
falls within the basic imaging 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 a
diagnostic mammogram (77065) provided October 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (73721) provided March 31,
2020.
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied
your request. The Plan says a corrected claim is needed.
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 73721 is not supported in the medical record. Specifically, the claim was billed with an
invalid revenue code. Based on this information, we decided that Medicare rules for coverage of the MRI have
not been met. Therefore, we decided that the Plan does not have to pay for Magnetic Resonance Imaging
(73721) provided March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral exam (D0120), prophylaxis (D1110), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on August 17, 2020.You asked the Plan to pay forthe dental services. You say that you did not have x-rays done with your first cleaning this year. You say that the x-rays you did have done were explained to you as bitewing x-rays.You also say that you are confused about what is covered under your policy.The Plan denied your request. The Plan says 1 periodic oral exam and 1 prophylaxis are covered per calendar year. The Plan says that the frequency limits for these services has been exceeded. The Plan says that periapical x-rays are not listed as covered services. The Plan also says that providers are receiving a separate stipend for the unspecified preventive services and cannot reimburse more for this 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 frequency limit of 1 periodic oral exam and prophylaxis per calendar year has been exhausted. The record shows that the Plan paid for the periodic oral exam and prophylaxis that you received on February 20, 2020. Additionally, periapical x-rays are not among the services listed under this benefit.Therefore, we decided that the Plan does not have to pay forthe periodic oral exam (D0120), prophylaxis (D1110), the periapical x-ray (D0220), and the unspecified preventive service (D1999) provided on August 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided on January 23, 2018, by
an out-of-network (OON) provider.
You asked the Plan to pay for the inpatient hospital care. You say that the care provided was not medically
necessary. The Plan denied your request. The Plan says the care provided was unauthorized post-stabilization
care and not medically necessary.
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 the inpatient hospital care. Our reviewer
says that the service was not medically necessary. Our physician reviewer found the review indicates that the
patient as of 12:44 AM on January 23, 2018 was hemodynamically stable and appropriate for ambulance
transport with monitoring to a Plan facility for continued observation/inpatient level of care services. Inpatient
care provided after 12:44 AM on January 23, 2018 through 11:41 PM on January 23, 2018 at the noncontracted Plan facility was not needed on an emergent basis. The review has determined that the treating
physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for
transfer on any dates of service.
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 inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the inpatient hospital care provided on January 23, 2018, by an out-of-network
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation and first intraoral periapical x-ray provided on September 14, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation and first intraoral periapical x-ray. You say that your EOC says that the exam should be covered at 50%.The Plan denied your request. The Plan says these services 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, 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 problem focused limited oral evaluation and first intraoral periapical x-ray provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing provided on July 28, 2020.
You asked the Plan to pay for the testing. You say that you would like reconsideration because this testing is
covered by Medicare. The Plan denied your request. The Plan says this test was ordered by a board-certified
internist.
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing may only be ordered by
licensed psychiatrists or neuropsychiatrists.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the testing have not been met. Specifically, the record shows that this testing was ordered by a
board-certified internist. There is no evidence that this provider also has boards in psychiatry or
neuropsychiatry. Therefore, we decided that the Plan does not have to pay for testing provided on July 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Adempas for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Adempas for the enrollee.
Benefits for this drug 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment formagnetic resonance imaging, brain (including brain stem)(70553) magnetic resonance imaging, spinal canal and contents (72156, 72157)You asked the Plan to waive the copayment forthe MRI. You say that you are requesting a significant reduction in your copay to an amount similar or comparable to that of last year.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $375 copayment for diagnostic radiology other than CT.You have been asked to pay $375 copayment for the MRI. The MRI falls 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 formagnetic resonance imaging, brain (including brain stem)(70553) magnetic resonance imaging, spinal canal and contents (72156, 72157)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services with CPT code S9328
provided from February 6, 2020, to June 22, 2020.
You asked the Plan to pay for CPT code S9328. 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 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.
We looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have
to pay for the home infusion therapy services with CPT code S9328 provided from February 6, 2020, to June
22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on August 26, 2020.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testingsolely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 22, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on July 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided on June 3, 2020.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 care could safely be provided at a custodial level of care as it had been prior to the skilled nursing facility admission.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Without records, it has not been shown that the skilled nursing care meets criteria or should be paid. Based on this information, we decided that Medicare rules for coverage of the skilled nursingservices have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99204) provided July 17, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the specialist visits 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 an office visit (99204) provided July 17, 2020.