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

We decided that the Plan does not have to pay for nerve conduction studies (95913) and needle electromyography (95886) provided on June 13, 2019.You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95913 is nerve conduction studies; 13or more studies.The CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the nerve conduction studies and needle electromyography. Our reviewer says that CPT code 95913 does not meet criteria for billing or reimbursement consideration. The medical record does not include documentation to validate that nerve conduction studies were performed. Our reviewer found CPT code 95886 does not meet criteria for billing or reimbursement consideration.  This code is an add-on code and the primary procedure, 99153, is denied. CPT code 95886 is not eligible for separate reimbursement consideration.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95913) and needle electromyography (95886) provided on June 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper denture provided on November 4, 2019.You asked the Plan to pay more for the complete upper denture. You say that you took out the policy to be covered 100%.The Plan denied your request. The Plan says the coinsurance applied correctly.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 Plan is only obligated to pay 30% of the cost for the complete upper denture.Therefore, we decided that the Plan does not have to pay more for the complete upper denture provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01230) provided on September 21, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support the service that was billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 01230 is anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the anesthesia services. Our reviewer says that CPT code 01230 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not document the total time spent administering anesthesia services.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01230) provided on September 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 5, 2019 to November 1, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a RAP is required in order to process the final 60-day episode of care claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record includes a billed RAP for a date of service that does not match the "from" date on the 60-day episode of care claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 5, 2019 to November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction services (92015) provided on November 14, 2019.You asked the Plan to pay for the refraction services. You say that you usually only pay $50 copay when you go to a specialists but when you went to this provider they made you pay $50 copay and $56 for his test and prescription for a single eye lens.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover for refraction.We looked at the file and the Plan's rules. Refraction is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met.Therefore, we decided that the Plan does not have to pay for refraction services (92015) provided on November 14, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided on December 10, 2019 to December 11, 2019.
You asked the Plan to waive the copayment for radiation treatment. You say that you are never late on your payments. You say that this copayment is too high. The Plan denied your request. The Plan says the correct copayment has been 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 $60 copayment for outpatient diagnostic tests/in-network/radiation. You have been asked to pay a $60 copayment for radiation treatment. The correct copayment has been applied to the service that was provided. Radiation treatment falls within the outpatient diagnostic tests/in-network/radiation 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 radiation treatment provided on December 10, 2019 to December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that moving the enrollee for oxygen weaning, completion of IV therapy, and rehab is best for the enrollee. The Plan denied your request. The Plan says the enrollee is not medically stable for transfer.
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 physician reviewer found that the enrollee was admitted to the acute care hospital with influenza A, pneumonia, and respiratory failure. She was noted to have acute kidney injury. C diff colitis was documented. A tracheostomy and a PEG tube were placed. Chronic respiratory failure is documented. LTACHs are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 she is currently receiving care. Consequently, the requested LTACH services are/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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that the treating provider ordered this testing to obtain medically necessary information for the enrollee's treatment.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 ordering physician 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 September 27, 2019 by an out of network (OON) provider.
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 it is felt that IRF would be best to get him ready to return home in 7-10 days. The Plan denied your request. The Plan says the criteria for IRF care are not 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 based on review of the available records, the patient does not meet criteria for IRF admission. The patient was medically stable with no evidence of need for supervision or acute rehab nursing care. He may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on her current functional status and medical stability. 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 reimburse you for the Bemer Mat Therapy System purchased on November 18, 2019.You asked the Plan to reimburse you for the Bemer Mat Device. You say that you cannot afford the payments for this device.The Plan denied your request. The Plan says this system is not a valid claim submission for Medicare.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. The device is registered with the FDA as a wellness device not a medical device.Therefore, we decided that the Plan does not have to reimburse you for the Bemer Mat Therapy System purchased on November 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 11, 2019.You asked the Plan to pay for the physician's services. You say that the enrollee was in a nursing home at the time of the services and could not choose an in-network optometrist. 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 service 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 physician's services providedon October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on July 31, 2019.
You asked the Plan to pay for CPT 95999. The Plan denied your request. The Plan says this is a bundled 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 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, train of four testing is not an unlisted procedure. There is a more appropriate CPT code for train of four testing. Additionally, train of four testing is a bundled procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of CPT 95999 have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on September 11, 2019.
You asked the Plan to pay for the molecular pathology services. You say that an in-network provider ordered this test to determine the appropriate treatment option for this enrollee. 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 and the ordering physician in this case are not network providers with the Plan. The Plan did not pre-approve 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 molecular pathology services provided on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the erythromycin ointment and fluorescein/proparacaine drops provided on October 13, 2018.
You asked the Plan to pay for these drugs. You say that The Plan denied your request. The Plan says that this is not a covered benefit under your contract under any normal circumstance.
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 pay for the erythromycin ointment and fluorescein/proparacaine drops provided on October 13, 2018.
Benefits for these drugs 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 pay for train of four monitoring (95999) provided on June 27, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says train of four is considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoring.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 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary procedure and is part of a bundled payment. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on June 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by the facility on November 5, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you were told that that you would not have a copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $150 copayment for outpatient diagnostic tests/CT scans. You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests/CT scans 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 CT scan provided by the facility on November 5, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the enrollee needs focused treatment and therapy to build up his strength.The Plan denied your request. The Plan says that the enrollee does not require complex daily nursing or skilled therapy services.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 pre-approve SNF care. Our physician reviewer found that the enrolleeis at risk for secondary complications of immobility such as pressure ulcers and contractures. He is also at risk for rapid decompensation secondary to his recent respiratory failure in current viral infection. He requires oversight of his medical conditions and medication management. Theenrollee has not returned to his prior level of function. He requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Herequires both daily skilled therapy and nursing services.He is unable to ambulate household distances.The enrollee'scondition would be expected to deteriorate with services provided on a less than daily basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the transthoracic echocardiography. We decided that the Plan does not have to reduce the coinsurance for the sulfur hexafluoride injections.
You asked the Plan to reduce the cost for the transthoracic echocardiography and sulfur hexafluoride injections. You say that you were previously charged $50 for the same procedure. You say that the billing should be corrected. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the cost for the transthoracic echocardiography.
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 each Medicare-covered standard x-ray and ultrasound. The transthoracic echocardiography is considered an ultrasound. Therefore, we decided that the Plan has to reduce the cost for the echocardiography from $136.94 to $50.
We also decided that the Plan does not have to reduce the cost for the sulfur hexafluoride injections.
Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered supplies. The allowed amount of the injections is $97.68 (20% x $97.68 = $19.53). Therefore, we decided that the Plan does not have to reduce the cost for the sulfur hexafluoride injections.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.