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

We decided that the Plan does not have to pay forthe laboratory services provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. 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.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (73030, Q0092, R0070) provided on August 13, 2019.You asked the Plan to pay forthe portable x-ray services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent and there was not pre-authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe portable x-ray services (73030, Q0092, R0070) provided on August 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an Esophogram(74220) provided on November 19, 2019 by provider.You asked the Plan to pay for the radiology procedure. You say that the service was medically necessary.The Plan denied your request. The Plan says the code at issue shares a Column I / Column II relationship with another code billed and cannot be paid separately.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 74220 has a bundled relationship with code 74230, which was already paid, 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 for an Esophogram (74220) provided on November 19, 2019 by provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).You asked the Plan to pre-approve a pneumatic compression device and sleeves. The Plan denied your request. The Plan says that the record sent by your provider indicates that you have not had a four-week trial of an E0650 or E0651 (a non-segmental compression pump).The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that you have had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 9, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this should be covered because it was an emergency. The Plan denied your request. The Plan says that the claim processed correctly with the correct member responsibility.
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 $265 copayment per date of service for ground ambulance transport regardless of the number of trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the per ground ambulance transport 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 the ambulance transport provided on November 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 18, 2019.
You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on February 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 13, 2018.
You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on December 13, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on October 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code G0180 was billed with an incorrect modifier.The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the file shows that code G0180 was billed with the -XE modifier, which is used in place of the -59 modifier to show a separate and distinct procedure services; however, the file shows that the code was billed as a standalone procedure. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services rendered on October 3, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe surgical services rendered on October 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that payment is included in the global surgical package.The Plan must follow Medicare rules. Medicare rules say that clearly distinct surgical procedures and post-operative complications that require a return trip to the OR are not included in the global surgical package.We looked at the file and Medicare rules. The file shows that the enrollee underwent a transcatheter aortic valve replacement (TAVR) for the date of service at issue. This procedureis not included in the global surgical package. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided thatthe Plan has to pay forthe surgical services rendered on October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.You asked the Plan to pre-approve Vyzulta. You say that the enrollee has been stable on this medication.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.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 Vyzulta.Benefits for Vyzulta 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 reduce the copayments forthe observation stay, the CT scan, and the nuclear medicine scan provided on December 21, 2019.You asked the Plan to reduce the copayments forthe observation stay, the CT scan, and the nuclear medicine scan. You say that you were only expecting to pay an $80 emergency room copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $210 copayment for each Medicare-covered outpatient hospital observation stay at a hospital facility and a $200 copayment foreach type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear scans andPET scans, per date of service. You have been asked to pay a $210 copayment for the observation stay, a $181.93 copayment for the CT scan, which is less than the standard copayment amount, and a $200 for the nuclear medicine scan. The observation stay falls within the "Outpatient hospital services" benefit category. The CT scanand the nuclear medicine scan fallwithin the "Outpatient diagnostic tests and therapeutic services and supplies"benefit category. The medical record shows you were admitted to an observation. This means that you have been asked topay 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 reduce the copayments forthe observation stay, the CT scan, and the nuclear medicine scan provided on December 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee on November 11, 2019 to November 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line on which the first four positions of the HIPPS code match the code submitted on the RAP. We looked at the file and Medicare rules. The home health claims were not billed with the required RAP. 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 home health services rendered to the enrollee on November 11, 2019 to November 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess cap 290mcg for the enrollee.
You asked the Plan to pre-approve the cap. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage.
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 Linzess cap 290mcg for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the requested item is necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided May 28, 2019 to June 18, 2019.
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says the services were billed with an incorrect occurrence code.
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 the services are not supported in the medical record. Specifically, services were billed with Occurrence Code 11. This is only suitable for use with outpatient claims. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services provided May 28, 2019 to June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe special pump services rendered to enrollee on August 16, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered to enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on October 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99152 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99152 is moderate sedation services byphysician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services rendered on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an ophthalmoscopy provided on
December 3, 2019.
You asked the Plan to pay for the physician's services. You say that the services were requested by the facility
where the enrollee is a long-term resident. You say the enrollee did not have any input in choosing who would
be her optometrist. The Plan denied your request. The Plan says non-emergent, non-urgent services with outof-
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
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 physician's services for an ophthalmoscopy provided on
December 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Eliquis tab 5mg for the enrollee.You asked the Plan to pre-approve the tab. You say that this is medically necessary.The Plandenied your request. The Plan says the requested medication is denied as a benefit exclusion.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 Eliquis tab 5mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 17, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 subsequent nursing facility care provided on December 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from December 3, 2019 to December 10,2019.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 this code 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 code.We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy (HCPCS S9328) provided to the enrollee from December 3, 2019 to December 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Monitoring (95999) provided on August 8, 2019.You asked the Plan to pay for the Train of Four Monitoring. 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 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 find that CPT code 95999 is not supported in the record. Specifically, Train of Four is considered integral tothe primary procedure and not eligible for separate reimbursement. 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 Trainof Four Monitoring (95999) provided on August 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveZofran (Ondansetron) 4mg tablets.You asked the Plan to pre-approveZofran. You say that Zofran is medically necessary.The Plan denied your request. The Plan says Zofran tablets can only be covered under the Part B Medical Benefit when they are used as an anti-emetic in conjunction with chemotherapy treatment.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. Oral anti-emetics such as Zofranare only covered under the Part B medical benefit when used in the context of chemotherapy treatment. The records submitted do not show a usage that fits this criteria.Therefore, we decided that the Plan does not have to pre-approveZofran (Ondansetron) 4mg tablets.Benefits for Zofranmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.