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

We decided that the Plan does not have to pay for diagnostic radiology provided on September 25, 2019.You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. The Plan saysthatthe 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 incases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case and the referring provider are notnetwork providers with the Plan. The Plandid not pre-approve the servicesat 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 diagnostic radiology provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on December 20, 2019.
You asked the Plan to waive the copayment for the visual field exam. You say that you did not see the doctor. You say that you should not have a copayment for a glaucoma scan. The Plan denied your request. The Plan says the copayment 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 a $15 copayment for Medicare-covered diagnostic procedures and tests. You have been asked to pay a $15 copayment for the visual field exam. The visual field exam 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 for the visual field exam provided on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for out-of-network (OON) dental services (D0120, D0274, D1110) provided on October 10, 2019.
You asked the Plan to waive the cost-share for OON dental services. You say that these services should be covered in full. The Plan denied your request. The Plan says these services processed 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 that covers services from both in-network and out-of-network providers, but you may be billed by the out-of-network provider for any amount greater than the payment made by the plan to the provider. The record shows that you have been asked to pay the amount charged by the OON provider in excess of the allowed amount. This means you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for out-of-network (OON) dental services (D0120, D0274, D1110) provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided August 12, 2019 to September 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided August 12, 2019 to September 23, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 5, 2019.
You asked the Plan to pay for the laboratory 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 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 December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 23, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were misdiagnosed and given medications that did not work. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayment 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 a $35 copayment for each visit. You have been asked to pay a $35 copayment for the urgent care visit. The urgent care visit falls within the "Urgently Needed 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 the urgent care visit provided on November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 21, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical. You say that you don't understand why an additional office visit was billed. The Plan denied your request. The Plan says the copayment 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 a $0 copayment for an annual physical by your primary care provider (PCP). If, during the physical exam, you also receive services to treat a medical condition, you will be expected to pay a $10 copayment for the additional, Medicare-covered services. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that hypertension was discussed during the office visit. 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 office visit provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the evaluation and management services provided to the enrollee on October 31, 2019. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that modifier 57 should only be used when the decision to perform surgery occurs on the day of or the day prior to the surgery. 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 99213 is office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. 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 services provided. Our reviewer says that the enrollee was seen for post-op, and evaluation of the second eye. A decision was made to proceed with surgery of the left eye on October 31, 2019. The rule for the use of the 57 modifier appended to an E/M code is as follows: "Modifier 57 should be appended to any E/M service on the day of or the day before said procedure when the E/M service results in the decision to go to surgery. This informs the payer that the physician determined the surgery was medically necessary." The medical records submitted do not indicate that procedure 66984 that was performed on October 31, 2019 was planned well in advance. As a result, the 99213-57 was used appropriately and is eligible for reimbursement. 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 provided have been met. Therefore, we decided that the Plan has to pay for the evaluation and management services provided to the enrollee on October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided September 29, 2019. You asked the Plan to pay for ambulance response and treatment, no transport. You say that you collapsed and EMS was called to check you out. After review of your vitals you were released and not transported to the hospital. You had a viable reason for their services and wish to appeal. The Plan denied your request. The Plan says this is not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 29, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided September 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on June 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed and there is a more appropriate code for these services. 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 services rendered June 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with computed tomography (CT) scan of the skull to thigh (78815).

You asked the Plan to pre-approve a PET CT scan of the skull to thigh. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET CT scan of the skull to thigh. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has been diagnosed with ductal carcinoma in situ (DCIS) left breast via needle biopsy and has not yet had an oncologic evaluation. CT of the chest, abdomen and pelvis and conventional bone scan have not been done. Per NCCN guidelines PET/CT is indicated if there are equivocal results based upon these tests and the records do not reveal they have been done. There are no lab values to indicate the likelihood of metastasis such as elevated alkaline phosphatase. NCD guidelines do not allow for PET coverage to stage for lymph node involvement either.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan of the skull to thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with computed tomography (CT) scan of the skull to thigh (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 64636 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 64636 is destruction by neurolytic agent, paravertebral
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint
(List separately in addition to code for primary procedure).
We find that CPT code 64636 is not supported in the medical record. Specifically, there is no documentation
that destruction by neurolytic agent of paravertebral facet joint nerves with imaging guidance was performed.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on October 3,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 24, 2019
through July 7, 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 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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found based on the documentation provided this hospitalization does not qualify for
inpatient payment under the two-midnight rule. At the time of admission, it was not reasonable to expect that
two midnights in the hospital would be required. The emergency department (ED) evaluation showed no
life/limb threatening condition(s). The enrollee could have been placed on observation status pending further
evaluation. As is, no life/limb threatening conditions were subsequently identified.
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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from June 24, 2019 through July 7,
2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate.
You asked the Plan to pre-approve Methotrexate. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 Methotrexate.
Benefits for Methotrexate 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861) provided on May 30, 2019.You asked the Plan to pay for the needle electromyography. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed place of service, 15, 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.We find that CPT code 95861 is not supported in the record. Specifically, the records indicate that this service was rendered to a hospital patient. Providers serving an entity for which another POS code exists, should use the POS code for that entity. Based on this information, we decided that Medicare rules for coverage of the needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography (95861) provided on May 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP panel rendered to the enrollee on October 14, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are
non-covered.
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code.
Furthermore, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay
for the CYP panel rendered to the enrollee on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered to the enrollee on July 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 are not payable.
The Plan must follow Medicare rules. The rules say that Medicare requires that services
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in
accordance with Medicare policies.
Medicare rules say that providers must produce medical records showing the services provided were billed
appropriately. In this case, there were insufficient records provided to show the provider in this case was
properly licensed to bill this service. Medicare billing criteria were not met. Therefore, we decided that the Plan
does not have to pay for the anesthesia services rendered to the enrollee on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chest x-ray (71046). You say that you would like reconsideration because the referring provider requested a chest x-ray for this member. The Plan denied your request. The Plan says these services were not authorized in compliance with the Plan's authorization procedures and the medical information received does not meet urgent or emergent care criteria.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 23, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health aide.You asked the Plan to pre-approve the aide. You say that this is medically necessary.The Plan denied your request. The Plan says the condition is chronic, and the care requested will not be intermittent.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 pre-approve the aide. Our reviewer says that the requested aide is not medically reasonable or necessary. Our physician reviewer found you received oral and ophthalmic medications and had stable vital signs. You had no pain. Your skin was intact. The nurse reconciledyour medications. The records do not show a decline in functional or medical status or care plan to warrant skilled nursing visits. Skilled nursing visits are not required to effectively provide treatment, care, and/or services which are medically necessary for you. The requested home health aide services were not medically necessary or reasonable to treat this beneficiary and are denied as dependent services.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 aide have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea home health aide.