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

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
August 14, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to
set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of
the procedure. The Plan denied your request. The Plan says payment for this service would be included in the
part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the pump assembly and operation have not been met. Specifically, the payment for this service is
included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the
assembly and operation of a pump (99190) provided on August 14, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from January 7, 2019 to February 7, 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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a G code and one of three Q codes. We looked at the file and Medicare rules. The claims were not billed with the required G code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered to the enrollee from January 7, 2019 to February 7, 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 the enrollee needs occupational, speech and physical therapy. The Plan denied your request. The Plan says that there are no complex medical needs requiring skilled nursing services.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by the out of
network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without 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 referring provider 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 August 14, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient services you received on May 23, 2019, and May 30, 2019.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 each x-ray and a $275 copayment for Medicare-covered outpatient hospital and observation services. Review of the file shows that you had an x-ray on May 23, 2019. You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the outpatient diagnostic services benefit category. Review of the file also shows that you were provided outpatient hospital services on May 30, 2019. Per you contract with the Plan, there is a $275 copayment for outpatient hospital services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $221.41. Given that the allowed amount was less than the $275 copayment, you have been asked to pay $221.41 for these services. This means that you have been asked to pay the correct amount ($236.41) based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient services you received on May 23, 2019, and May 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a thyroid biopsy (60100) provided on August 5, 2019.
You asked the Plan to waive the copayment for a thyroid biopsy. You say that you were told there would not be a copayment for this service. The Plan denied your request. The Plan says this service processed 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 $150 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $150 copayment for a thyroid biopsy. A thyroid biopsy falls within the benefit category of Medicare-covered surgery or other services provided to you at an outpatient hospital. 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 a thyroid biopsy (60100) provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, and the ultrasonic guidance for needle placement provided on August 13, 2019 by out of network provider.
You asked the Plan to pay for the physician services. You say that the services were emergent. You say that you could not wait for your primary doctor for a referral. You also say that you have seen the doctor before for your feet. The Plan denied your request. The Plan says authorization was not obtained before you received the services. The Plan says your primary care physician did not refer you for the services. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The Plan has confirmed there are 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 office visit, and the ultrasonic guidance for needle placement provided on August 13, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on June 25, 2019 and July 17, 2019.
You asked the Plan to waive the copayments for specialist visits. You say that you feel that you are being
overcharged. 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 $45
copayment for a specialist visit.
You had specialist visits on June 25, 2019 and July 17, 2019. Therefore, you are responsible to pay a $45
copayment per each visit. The total amount you owe is: $90.00.
You have been asked to pay the total copayment amount of $90.00 for specialist visits. Specialist visits fall
within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided on June 25, 2019 and July 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99310) provided on August 26, 2019.
You asked the Plan to pay for subsequent nursing facility care. You say that the enrollee lives in a long term care facility and wanted to establish primary care as the providers to come to the facility and render care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 subsequent nursing facility care (99310) provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549 for the enrollee.You asked the Plan to pre-approvethe compression stockings. You say that these are medically necessary.The Plan denied your request. The Plan says that these items are not covered by Medicare.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided during a craniotomy and tumor resection on November 30, 2018.
You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary and should be paid. The Plan denied your request. The Plan says Medicare does not pay for surgical assistant services provided by licensed surgical assistants.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided during a craniotomy and tumor resection on November 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit coded 99213 provided on August 8, 2019.You asked the Plan to pay forthe office visit. 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 payable.The Plan must follow Medicare rules. Medicare rules say that providers mustreport 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 find that CPT code 99213 is not supported in the medical record. Specifically, this code is bundled as part of the global surgical fee because it was reported within 90 days of the major surgical procedure coded 47135 (Liver allotransplantation).Therefore, this code is not separately payable.Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.Therefore, we decided that the Plan does not have to pay forthe office visit coded 99213 provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chronic case management services (99491 and 99487) provided from May 15, 2019 to August 19, 2019.
You asked the Plan to waive the copayment for the chronic case management services. You say that you feel you should not be responsible for this cost share amount. You would like the plan to reconsider your request. The Plan denied your request. The Plan says you received physician services on the dates of service at issue in this appeal. The plan states the correct copayments have applied per your contract with the plan.
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 $10 copayment for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received physician services provided from May 15, 2019 to August 19, 2019. You have been asked to pay a $10 copayment for each chronic case management service. The chronic case management services fall within the Physician/Practitioner 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 chronic case management services (99491 and 99487) provided from May 15, 2019 to August 19, 2019.
Your complaint about the provider not providing services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar/Sacral Facet Joint Radiofrequency Neurolysis for the enrollee.
You asked the Plan to pre-approve Lumbar/Sacral Facet Joint Radiofrequency Neurolysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain 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 Lumbar/Sacral Facet Joint Radiofrequency Neurolysis. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had a diagnostic sacroiliac joint injection with 50% pain relief. The requested procedure is considered experimental/ investigational because of the wide variation in reported efficacy in the peer review literature. Therefore, the enrollee does not meet criteria for the requested 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 Lumbar/Sacral Facet Joint Radiofrequency Neurolysis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lumbar/Sacral Facet Joint Radiofrequency Neurolysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the clinic visit and x-rays provided on July 26, 2019.
You asked the Plan to reduce the copayments for the clinic visit and the x-rays. You say that you should only be responsible for a total of $30 for the x-ray and the office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan confirmed that the provider is only charging a $10 copayment for the clinic visit and the provider bills x-rays through the outpatient hospital department.
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 $10 copayment for convenience care/retail clinic visit and a $100 copayment per visit for outpatient hospital services. You have been asked to pay a $10 copayment for the clinic visit and a $100 copayment for the x-rays. The clinic visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-rays fall within the "Outpatient hospital 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 reduce the copayments for the clinic visit or the x-rays provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services
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 the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5
years or older."
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 code 99152 is not
supported. The record does not contain evidence that moderate sedation was performed with the presence of an
independent, trained observer.
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 moderate sedation services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) and administration (90471) provided on May 14, 2019.
You asked the Plan to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration. You say that your doctor advised you to get this vaccination and you assumed it would be covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus, diphtheria toxoids and acellular pertussis vaccine and administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715) and administration (90471) provided on May 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (code D3330) provided on July 31, 2019.
You asked the Plan to pay for the endodontic therapy. You say that the enrollee was in pain and was told she needed a root canal and tooth extraction. You also say that the enrollee was told that the root canal would be covered by her insurance. The Plan denied your request. The Plan says this service is not a listed benefit of the enrollee's Plan.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (code D3330) provided on July 31, 2019.