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

We decided that the Plan does not have to pay for train of four testing provided on October 3, 2019.
You asked the Plan to pay for train of four testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled payment.
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 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 train of four testing. Our reviewer says that unlisted CPT code 95999 was reported for train of four testing. Our physician reviewer found train of four is included in other intraoperative neuromonitoring procedures and is not separately reportable. Reporting train of four testing with unlisted CPT code 95999 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing provided on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 24, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.
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 laboratory 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 laboratory services provided on July 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay forlab services provided on August 22, 2019.You asked the Planto pay forthe services. You say that the enrollees are homebound, and don't have the option of choosing whom they see for lab services.The Plandenied your request. The Plansaysthese services must be provided a contracted laboratory.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 rendering 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 Plandoes not haveto pay forlab services provided on August 22, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0481 provided on June 7, 2019.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed.We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. The submitted Laboratory Requisition indicates that 389 -New Gen Labs: Oral Swab Profile was requested. The submitted documentation does not itemize what tests are included in this panel; therefore, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded G0481 provided on June 7, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 30, 2019 through July 2, 2019.You asked the Plan to pay forinpatient hospital care. You say that the stay was medically necessary.ThePlan denied your request. The Plan says after five faxes and phone calls to the provider to gain clinical documentation, none was received.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. With the information we have, we cannot determine if a physician's order was given, how the member came to you, the referring provider, or whether the services are medically necessary.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from June 30, 2019 through July 2, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for measuring glucose (sugar) in the blood (82947) provided on August 6, 2019 by out of network provider.
You asked the Plan to pay for measuring glucose (sugar) in the blood. You say that you are appealing claim payment denial for services rendered to the Plan's member on date of service August 6, 2019. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 measuring glucose (sugar) in the blood (82947) provided on August 6, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (CPT Code E2359), (CPT Code E1012), (CPT Code E2311) and (CPT Code K0856), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. In order for the requested services to be covered, the enrollee would need to have such things as: provider notes showing an onsite home evaluation was done prior to the delivery of the wheelchair. The records received do not indicate any of the above. Based on Medicare guidelines, the F3 Color Kit - Carbon Fiber (wheelchair component or accessory, not otherwise specified) you are requesting do not meet the requirements for approval. We reviewed your records and they show the enrollee has weakness on one side of their body. The enrollee needs a power wheelchair to help the enrollee with their activities of daily living. The Medicare guidelines say that this item or service is not a covered benefit as it is not medical in nature. Under Medicare, the request is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve (CPT Code E2359), (CPT Code E1012), (CPT Code E2311) and (CPT Code K0856), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gemtuzumab ozogamicin injection provided on May 7, 2019.You asked the Plan to waive the coinsurance forthe gemtuzumab ozogamicin injection. You say that according to the statement your share of the cost is $0. You say that you want to know if the invoice amount is covered by insurance.The Plan denied your request. The Plan says the coinsurance applied correctly.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 Medicare-covered Part B drug.You have been asked to pay $1,455.77, which is less than the standard 20% coinsurance for the gemtuzumab ozogamicin injection because you met your maximum out-of-pocket. The gemtuzumab ozogamicin injection falls within the "Medicare Part B Prescription Drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe gemtuzumab ozogamicin injection provided on May 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetes self-management training (G0180) provided on July 16, 2019 by out of network provider.
You asked the Plan to pay for diabetes self-management training. You say that this service was medically necessary. The Plan denied your request. The Plan says this service was not authorized.
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 diabetes self-management training (G0180) provided on July 16, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pare-approve a re-evaluation for the continuation of physical therapy.You asked the Plan to pare-approve the physical therapy. You say that you recently fell and would like physical therapy to gain strength. The Plan denied your request. The Plan says the clinical documentation does not show you need the ongoing skills of a physical therapist.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 pare-approve the physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment or that the services can be safely and effectively performed only by a therapist.
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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pare-approve a re-evaluation for the continuation of physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided to the enrollee on June 28, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) codes 28113 and 11047 remain 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 the denied codes is: CPT 28113: ostectomy, complete excision; fifth metatarsal head CPT 11047: Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT code 28113 is not supported by the medical record. The record does not contain evidence that a complete excision of the 5th metatarsal head was performed. The record describes the removal of bone due to osteomyelitis. According to CPT rules, there is a more specific code for this procedure. CPT code 11047 is not supported. The record does not contain evidence that any measured debridement of bone was performed during this episode of care. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry services provided to the enrollee on June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99202, CPT 72082) you received on June 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these are not covered services.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 99202, CPT 72082) you received on June 7, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the IV infusions provided on July 15, 2019.
You asked the Plan to waive the coinsurance for the IV infusions. You say that you received an additional bill for services provided during the emergency room visit. You say that the cost should be covered under the ER copayment. The Plan denied your request. The Plan says that the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a $90 copayment for emergency services in an emergency room and a $0 copayment for provider and professional services in an emergency room. The Plan says the enrollee must pay 43.32 for the IV infusions. Based on the plan contract, however, the enrollee cannot be asked to pay more than $0 for the IV infusions. The IV infusions are considered a physician service that were provided during the emergency room visit. Therefore, we decided that the Plan has to waive the coinsurance for the IV infusions provided on July 15, 2019.
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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve the Retacrit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the member does not meet coverage criteria for Retacrit.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Retacrit. Our reviewer says that based on the provided medical records, the member's iron stores are not sufficient to support that Retacrit is medically reasonable and necessary. Our physician reviewer found the records do not indicate that Retacrit is safe and effective for this member. 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 13, 2019 by out of network provider.You asked the Plan to pay formental health services. You say that you would like this claim to be reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 servicesprovided on May 13, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 23, 2019 through July 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 23, 2019 through July 6, 2019.
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.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 22, 2019 through March 25, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 22, 2019 through March 25, 2019.
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.