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

We decided that the Plan does not have to pay for outpatient hospital services provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were non-emergent services.
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 outpatient hospital services provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 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 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 laboratory services rendered on April 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml provided on December 4, 2019 and December 18, 2019.
You asked the Plan to waive the coinsurance for this drug. The Plan denied your request. The Plan says that you are responsible for the coinsurance.
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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for this drug. this drug 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 for the phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml provided on December 4, 2019 and December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea single-photon emission computed tomography (SPECT) test.You asked the Plan to pre-approveSPECT test. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the criteria for this testing.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SPECT test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has mild coronary risk, very atypical symptoms, a normal cardiac physical examination, normal electrocardiogram, and normal echocardiogram. In these circumstances the pre-test likelihood of coronary ischemia is low such that if further cardiac evaluation were thought to be medicallynecessary, then a standard treadmill electrocardiogram should be sufficient. Current guidelines do not recommend nuclear stress testing in patients who are able to exercise, have a normal (interpretable) baseline electrocardiogram, and have low pre-test risk. The requested testing exceeds the enrollee's medical needs 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 SPECT test have not been met.Therefore, we decided that the Plan does not have to pre-approvea single-photon emission computed tomography (SPECT) test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge day management services coded 99217.
You asked the Plan to pay for the observation care discharge day management services. 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 separately payable.
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 99217 for the observation care discharge day management services has a bundled relationship with code 99219 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 the observation care discharge day management services coded 99217.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis procedures provided on December 26, 2019 to December 30, 2019 by an out of network (OON) provider. You asked the Plan to pay for dialysis procedures. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network. 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 dialysis procedures provided on December 26, 2019 to December 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora podiatry office visit provided on March 4, 2020 by an out of network (OON) provider.You asked the Plan to pay fora podiatry office visit. You say that you were referred by your primary care physician. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that no referral was on file for these services; therefore, these services cannot be approved for payment.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 fora podiatry office visit provided on March 4, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided at August 28, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 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 an ER visit provided at August 28, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient psychotherapy services provided on November 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient psychotherapy services. You say that the member was brought in by a family member due to concerns of possible progressive memory loss and confusion. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was provided. The Plan says that the member's primary care physician did not refer these services.
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 outpatient psychotherapy services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided from November 18, 2019 to December 13, 2019. You asked the Plan to pay for the nurse practitioner 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 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 nurse practitioner services provided from November 18, 2019 to December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0150) and prophylaxis (D1110) provided on November 6, 2019 by an out of network dentist.
You asked the Plan to pay for the dental services. You say that you were not notified that the dentist in this case was not in the network. You say that you did not know until you got the denial notice. You also say that you do not feel like it should be your responsibility to pay for the services. The Plan denied your request. The Plan says the dentist in this case is not a network provider. The Plan also says care rendered by a provider that is not part of our supplemental dental network is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0150) and prophylaxis (D1110) provided on November 6, 2019 by an out of network dentist
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by an outpatient hospital on December 23, 2019. You asked the Plan to waive the copayment for an outpatient surgery. You say that it wasn't your fault one of the plates became loose and you had to get an additional surgery. The Plan denied your request. The Plan says the correct copayment has been applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for outpatient surgery/in-network/outpatient hospital facility. You have been asked to pay a $325 copayment for an outpatient surgery. Since an outpatient surgery as provided, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital facility 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 an outpatient surgery provided by an outpatient hospital on December 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that the records provided show that the member is unable to participate in therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitriptyline tablets.
You asked the Plan to pre-approve Amitriptyline. You say that this medication is the only one that can help the enrollee sleep. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D 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 Amitriptyline tablets.
Benefits for Amitriptyline 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered on December 2, 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 the panel must be billed with procedure code 81479. The file shows that the panel was not billed with code 81479 but as a panel of codes. 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 testing rendered on December 2, 2019.
The Plan references Local Coverage Determination (LCD) L35000 in their determination; however, this LCD is not binding for the state of California where the single-source test was performed and was not used in the MAXIMUS determination.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay further for the inpatient hospital services rendered in a foreign country from January 17, 2019 to January 28, 2019.
You asked the Plan to pay further for these services. You say that you are disputing the dollar amount reimbursed. The Plan denied your request. The Plan says the claim was processed correctly.
The Plan must follow Medicare rules. The rules say that Medicare may pay for inpatient hospital services you get in a foreign country. We looked at the file and Medicare rules. The file shows that you received inpatient hospital services while in a foreign country. The Plan reimbursed you a total of $95,841.10 in US dollars for these services, based on the conversion rate from currency. The claim was properly reimbursed and no further payment can be made. Therefore, we decided that the Plan does not have to pay further for the inpatient hospital services rendered in a foreign country from January 17, 2019 to January 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on December 11, 2019.
You asked the Plan to waive the copayment for the biopsy. You say that the biopsy was coded as a surgical procedure instead of a diagnostic procedure. You say that the copayment should be $25. 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 $250 copayment for Medicare-covered surgery or other services at an in-network, outpatient hospital or an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $250 copayment for the biopsy. The biopsy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The biopsy is considered a surgical procedure. 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 biopsy provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin barrier wipes or swabs rendered on October 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 procedure code A5120 was billed with an improper modifier.The Plan must follow Medicare rules. The rules say that modifier AU is used for supplies related to urological, ostomy, or tracheostomy supply and modifier AV is used for supplies related to a prosthetic or orthotic device.We looked at the file and Medicare rules. The file shows that procedure code A5120 was used in relation to colostomy supplies and was not billed with the AU or AV modifier. The code was billed incorrectly with the KX modifier. 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 skin barrier wipes or swabs rendered on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelumbar epidural injections.You asked the Plan to pre-approvethe requested injections. The Plan denied your request. The Plan says the documentation did not show that a prior injection resulted in a substantial relief of pain.The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are only covered under certain medical indications.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 requested injections. Our physician reviewer found that you have chronic low back pain and right sided sciatica with a history of a disc osteophyte complex at L5-S1 and disc protrusion at L4-5. You received epidural steroid injections in 2012 and 2014 with good results. Documentation of prior physical therapy was not provided. A request was submitted for a series of 3 caudal epidural injections. Per the coverage criteria, there is norole for series of threeepidurals. Response to each epidural should be determined prior to determining the value of a repeat epidural and the specific methodsused for subsequent epidurals. The Plan requires documentation of at least 80% improvement for 8 weeks from epidural steroid injection for approval of subsequent injections.The response to the injection approved for May 7, 2020, has not been provided.Therefore, it is not medically necessary and reasonable for this enrollee to have a series of 3 caudal epidural injections as requested. 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 requested injections have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar epidural injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis procedure rendered on May 1, 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 patient height is used to adjust and make calculations
to the final payment rate for ESRD services.
We looked at the file and Medicare rules. The claim was not billed with the required patient height. 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 dialysis procedure rendered on May 1, 2019.