Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on November 14, 2019.You asked the Plan to pay for the therapeutic exercises. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 97110 was not billed with an appropriate modifier. The Plan must follow Medicare rules. Medicare rules say that the claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered: - GN Services delivered under an outpatient speech-language pathology plan of care;- GO Services delivered under an outpatient occupational therapy plan of care; or, - GP Services delivered under an outpatient physical therapy plan of care. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises have not been met. Specifically, the submitted claim does not include the required modifier. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transfusions (36430) provided on October 10, 2019
You asked the Plan to pay for the transfusions. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the provider billed two units of this service
while the MUE value for this code is 1 and MAI value of 2.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 36430 is 1 and the MAI is 2, meaning this code will not be paid twice by
Medicare for the same date of service. You billed 2 units of this code, exceeding the MUE. Based on this
information, we decided that Medicare rules for coverage of the transfusions have not been met. Therefore, we
decided that the Plan does not have to pay for transfusions (36430) provided on October 10, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on September 20, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the ordering provider's progress notes were not submitted.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sales tax for services received on October 9, 2019.
You asked the Plan to pay for the sales tax. You say that this should be paid for. The Plan denied your request.
The Plan says this is an invalid procedure code for this 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 definition of HCPCS code S9999 is "sales tax."
We find that HCPCS code S9999 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 sales tax
have not been met. Therefore, we decided that the Plan does not have to pay for sales tax for services received
on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153) provided on July 10, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of 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.We find that CPT code 99153 is not supported in the record. Specifically, 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility and may only be billed by the facility. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on April 11, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to enrollee on April 11, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing rendered to enrollee on October 19, 2018.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 testing is not covered.The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare.The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication.Therefore, we decided that the Plan does not have to pay for the 4Kscore testing rendered to enrollee on October 19, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forobservation care provided from September 25, 2019 through September 26, 2019.You asked the Plan to waive the copayment forobservation care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation care provided from September 25, 2019 through September 26, 2019. You are asked to pay a $350 copayment for the observation care. 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 forobservation care provided from September 25, 2019 through September 26, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of coverage for Fasenra (J0517) to be given every four weeks at an outpatient infusion center.You asked the Plan to pre-approve the Fasenra every four weeks to be given at an outpatient infusion center. You say that your symptoms increase around 6 weeks. The Plan denied your request. The Plan says this is not an appropriate dose for your condition.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 Fasenra every four weeks to be given at an outpatient infusion center. Our reviewer says that there is no evidence to support the use of Fasenra every four weeks once the first three initial doses are administered. Our physician reviewer found there are no clinical trials evaluating the efficacy and safety of a decreased interval between doses.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 Fasenra every four weeks to be given at an outpatient infusion center. have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of coverage for Fasenra (J0517) to be given every four weeks at an outpatient infusion center.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI of the brain provided on July 23, 2019.
You asked the Plan to pay for the MRI. The Plan denied your request. The Plan says that 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 MRI of the brain. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the MRI of the brain provided on July 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forEmergency Room services provided on September 11, 2019. You asked the Plan to pay forthe emergency room services. You say that the services were medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for the services at issue.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forEmergency Room services provided on September 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 9, 2019.You asked the Plan to pay for the train of four monitoring. You say that the services rendered were medically necessary. 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 find that CPT code 95999 is not supported in the medical record. Specifically, payment for trainof four monitoring is bundled as part of the payment for the primary neuromonitoring procedure. 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 January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe wound care services provided from September 3, 2019 to October 18, 2019.You asked the Plan to waive the copayments forthe wound care services. You say that you were never informed that each visit would be billed as outpatient surgery. You say you stopped going because you are living on a fixed income. The Plan denied your request. The Plan says you havebeen 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 youmust pay a $250 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have beenasked to pay a $250 copayment for each of the wound care services. ($250 x 6 dates of service = $1,500). The wound care services fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 thePlan does not have to waive the copayments forthe wound care services provided from September 3, 2019 to October 18, 2019.
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 this is medically necessary. The Plan denied your request. The Plan says the medical record must document medical necessity of close physician involvement.
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 the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy can allow for measurable gains to be attained within a reasonable period. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye and medical examination for diagnosis and treatment (92012) provided on September 16, 2019 by an out of network (OON) provider.You asked the Plan to pay foran eye and medical examination for diagnosis and treatment. You say that you are appealing the claim denial for services rendered to the member on September 16, 2019. Please see the notes that support the need for service.The Plan denied your request.The Plan says the physician is a non-participating provider. The plan did not authorize any services for the physician. There are multiple in-network providers within 30 miles of the members residence that could have renderedthe services. The services were not considered urgent/emergent in nature. Services rendered by nonparticipating providers, 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 foran eye and medical examination for diagnosis and treatment (92012) provided on September 16, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine transportation.You asked the Plan to pre-approveroutine transportation. You say that the routine transportation services to your medical appointments are necessary since you are not confident in driving far distances.The Plan denied your request. The Plan says routine transportation is not a covered benefit. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveroutine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MYD88 and RUNX1 genetic testing rendered to the enrollee on June 24, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that MYD88 and RUNX1 testing are covered for specific diagnoses only. We looked at the file and Medicare rules. The file shows that the enrollee received MYD88 and RUNX1 testing for a diagnosis of unspecified myelodysplastic syndrome. This is not a diagnosis for which these tests are covered. Therefore, we decided that the Plan does not have to pay for the MYD88 and RUNX1 genetic testing rendered to the enrollee on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee. You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires daily doctor visits, special nursing care, and rehab therapies.The Plan denied your request. The Plan says the enrollee does not have a complex illness requiring further hospital care.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 in the case of this enrollee, although there was a prolonged illness including pneumonia and acute respiratory failure, improvement was noted, showing weaning off of mechanical ventilation and completion of antibiotics successfully. Recent plans for discharge in the near future are reasonable. However, ongoing pulmonary issues requiring closer monitoring and nursing care as well as continued steroid taper should be supervised in an acute care setting. This additional supervision and care shouldn't lastmore than 25 days prior to improving enough to discharge to a lower level of care. The services available and covered at the current facility are sufficient. There are no additional services needed that only the LTACH would offer. Therefore, this request for LTACH services will be considered not medically necessary 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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon August 16, 2019.You asked the Plan to pay for the physician's services. 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 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 physician's services provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of triamcinolone acetonide (J3301) provided on September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foran injection of triamcinolone acetonide. You say that you were unaware that the physician is not par with this patient's policy since he is par with this patient's plan. Please allow a onetime courtesy to have this claim paid since it's your first time billing this policy.The Plan denied your request. The Plan says the member has no out of network benefits. The non-urgent services are not authorized because  a non-network provider with the member's health plan, and member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requiresauthorization 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 onlyin 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 foran injection of triamcinolone acetonide (J3301) provided on September 23, 2019 by an out of network (OON) provider.