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

We decided that the Plan does not have to pay forthe hospital discharge day management services coded 99239 provided on November 6, 2019.You asked the Plan to pay forthe hospital 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 supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Inthis case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted did not include a hospital day management note with a recorded duration of time of 31 minutes or more for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay forthe hospital discharge day management services coded 99239 provided on November 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SPECT test provided on December 2, 2019.You asked the Plan to waive the copayment forthe SPECT test. You say that you would like all of the services covered.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 $275 copayment for each advanced imaging service (e.g., MRI, CT, and PET scan, nuclear medicine, and stress tests). You have been asked to pay a $275 copayment for the SPECT test. The SPECT test 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 forthe SPECT test provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay provided on June 26, 2019 to July 2, 2019 by an out of network (OON) provider.You asked the Plan to pay for an inpatient hospital stay. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for 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 an inpatient hospital stay provided on June 26, 2019 to July 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger coded 99190 provided on October 23, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. 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, the CPT Code Manual definition of code 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically,the enrollee was inpatient in the hospital for these services. The payment for these services billed while the enrollee is inpatient in the hospital is included in the DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger have not been met.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger coded 99190 provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator (CPT Code E1390) provided to the enrollee on November 25, 2019 by an out-of-network provider. You asked the Plan to pay for the DME. You say that the services were rendered to the patient and under that patient's plan you are an out-of-network provider. You state the member refuses to use any other DME supplier. The Plan denied your request. The Plan says the Medicare rules have not been met. 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. Based on the documentation the DME is not necessary. The prescription is out of date (May 25, 2017) and last Oximetry Testing was done in 2008. A more current physician's order would be required as well as current oximetry testing results. Furthermore, the enrollee does not have out-of-network benefits. 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 oxygen concentrator (CPT Code E1390) provided to the enrollee on November 25, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided to the enrollee from February 10, 2018 through May 10, 2018.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the claims were submitted outside of the 12 month/ 1 calendar year the Plan allows for claims submission.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the DME was not filed until October 31, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the DME provided to the enrollee from February 10, 2018 through May 10, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill
or critically injured patient; first 30-74 minutes (CPT Code 99291) and critical care, evaluation and
management of the critically ill or critically injured patient; each additional 30 minutes (CPT Code 99292)
provided from March 23, 2019 through March 24, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the medical records do not support 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.
Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. The documentation
submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The
documentation does not include the time spent providing this service; therefore, the billed Critical Care
Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact
the provider for additional information.
Current Procedural Terminology (CPT) code 99292 (1 unit) remains not supported. The required primary
service code (CPT code 99291) is denied (Reason Code 191); therefore, this service cannot be reimbursed
separately. In addition, the documentation submitted did not support a critical care visit of an additional 30
minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management
service (Current Procedural Terminology (CPT) code 99291) for this date of service. The documentation does
not include the time spent providing this service. It is noted that multiple attempts were made to contact the
provider for additional information.
Current Procedural Terminology (CPT) code 99292 (1 unit) remains not supported. The required primary
service code (CPT code 99291) is denied (Reason Code 191); therefore, this service cannot be reimbursed
separately. In addition, the documentation submitted did not support a critical care visit of an additional 30
minutes of critical care time in addition to the first 30-74 minutes of a critical care evaluation and management
service (Current Procedural Terminology (CPT) code 99291) for this date of service. The documentation does
not include the time spent providing this service. It is noted that multiple attempts were made to contact the
provider for additional information. Therefore, we decided that the Plan does not have to pay for critical care,
evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code
99291) and critical care, evaluation and management of the critically ill or critically injured patient; each
additional 30 minutes (CPT Code 99292) provided from March 23, 2019 through March 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) and deluxe frame (V2025) provided on September 26, 2019 by an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that you called customer service and were told that your plan would pay $200 on a pair of eyeglasses. The Plan denied your request. The Plan says you called the customer service department after you purchased the eyewear and benefits discussed were for the routine eye wear, however you received eyewear following your cataract surgery which is covered as a separate benefit as per which upgrades to lenses and frames are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. This is not covered by Medicare after cataract surgery. The Plan states upgrades on lenses and frames are not covered and there is no supplemental plan benefit beyond the standard frames and lenses covered by Medicare. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) and deluxe frame (V2025) provided on September 26, 2019 by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency medicine services (CPT 27250) provided to the enrollee on September 4, 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 CPT 27250 is disallowed with modifier 54.
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 27250 is "Closed treatment of hip dislocation, traumatic." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT 27250 in its description describes it as a "closed" procedure. Adding modifier 54 to this code in inappropriate as it applies to a "surgical procedure." We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for emergency medicine services (CPT 27250) provided to the enrollee on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lonhala Magnair 25mcg refill.You asked the Plan to pre-approve Lonhala Magnair 25mcg refill. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveLonhala Magnair 25mcg refill.Benefits for Lonhala Magnair 25mcg refill 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio.You asked the Plan to pre-approve Zarxio. You say that the requested Zarxio is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Neupogen AND Nivestym first.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Zarxio. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found this review relates to a request for Zarxio for expected neutropenia due to chemotherapy with 5FU, Irinotecan, Leucovorin, and Oxaliplatin with first treatment in 4/2020. The submitted documentation does not indicate that either Neupogen (Fillgastim) or Nivestym (Filgrastim-aafi) have been tried. Neupogen and Nivestym and Zarxio are all indicated to decrease the incidence of infection as manifested by febrile neutropenia in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant incidence of severe neutropenia with fever. The NCCN Guidelines Version 2.2020 Hematopoietic Growth Factors states that an FDA approve biosimilar is an appropriate substitute for Filgastim and Pegfilgastrim. Therefore the plan's required drugs would not be less effective or likely to have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that Medicare rules for coverage of Zarxio have not been met.Therefore, we decided that the Plan does not have to pre-approve Zarxio.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the physical therapy services you received on November 20, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that no proof of payment was received. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $30 copay for outpatient rehab services. The file shows that you received physical therapy services on November 20, 2019. You sent MAXIMUS proof of payment for the date of service at issue in this appeal. Based on the information provided, we decided that the rules for coverage have been met. Therefore, we decided that the Plan has to pay for the physical therapy services you received on November 20, 2019 based on your plan benefits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on December 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 forthe medical services provided to you by an out-of-network provider on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit coded G0439 and the brief emotional/behavioral assessment coded 96127 provided on September 25, 2019. You asked the Plan to pay for the annual wellness visit and the brief emotional/behavioral assessment. 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 a covered benefit. The Plan must follow Medicare rules. The rules say that an annual wellness visit is covered once every 12 months. Medicare rules also say that providers must report services correctly. Review of the file shows that an annual wellness visit was previously billed and processed by the plan for the same date of service and same provider. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 96127 for the brief emotional/behavioral assessment has a bundled relationship with code G0439 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 annual wellness visit coded G0439 and the brief emotional/behavioral assessment coded 96127 provided on September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Octagam 20gm/200ml IV solution medication.You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denialas this medication is a new method of treatment for the enrollee and should be covered under Medicare Part B.The Plan denied your request. The Plan says this medication is not eligible for coverage under the Medicare Part B benefit.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part Bcoverage.Therefore, we decided that the Plan does not have to pre-approvethe Octagam 20gm/200ml IV solution medication.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from August 26, 2019, to September 3, 2019.You asked the Plan to pay forthe services. You say that you were told this provider was in-network.The Plan denied your request. The Plan says these services were available in-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 providersonly 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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider from August 26, 2019, to September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided to the enrollee on September 12, 2019.
You asked the Plan to pay for the testing services. You say that the test was provided to properly treat or diagnose the enrollee. The Plan denied your request. The Plan says the electronic signature did not correlate with the billed date.
The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary.
We find that CPT code G0481 is not supported in the records. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing provided to the enrollee on September 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing 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.
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 skilled nursing services provided on November 5, 2019 by an out of network (OON) provider.