Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554) provided to the enrollee.
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 no information was provided to show if the services were medically necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. With the information we have, we cannot determine how the member came to the servicing provider or whether the services are medically necessary. Non-contracted providers are required to furnish necessary information to the health plan when requested. After three or more attempts to obtain information, none was received as of this date. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT Code K0553) and receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system (CPT Code K0554) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921) and core buildup, including any pins when required (D2950) provided on June 27, 2019.
You asked the Plan to pay for the dental services. You say that you lost the cap on the front tooth and wanted to replace the cap. You state the dentist said more work would be required and that you ended up getting a credit card to pay for services. The Plan denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for unspecified periodontal procedure, by report (D4999), gingival irrigation - per quadrant (D4921) and core buildup, including any pins when required (D2950) provided on June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the blood draw, and laboratory testing provided by the out of network provider.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them 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 referring provider is not a network provider either. 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 blood draw, and laboratory testing provided by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on July 18, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.
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 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 record does not indicate that more than 30 minutes of hospital discharge day management services were rendered. 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 for more than 30 minutes of hospital discharge day management services (99239) provided on July 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee.
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 95870 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95870 is needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters. We find that CPT code 95870 is not supported in the medical record. Specifically, the records show that needle electromyography of two extremities was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), removal of benign odontogenic cyst or tumor (D7450) and deep sedation/general anesthesia - first 15 minutes (D9222) provided by an out-of-network provider from June 26, 2019 through July 17, 2019.
You asked the Plan to pay for the dental services. You say that you were aware that the provider opted out of Medicare, but the services you received were necessary for you. The Plan denied your request. The Plan says the provider has opted out of Medicare. The Plan states you only have non-routine dental benefits and no coverage for regular dental benefits.
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. The provider does not participate with Medicare and has opted-out of Medicare and you only have non-routine dental benefits. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140), removal of benign odontogenic cyst or tumor (D7450) and deep sedation/general anesthesia - first 15 minutes (D9222) provided by an out-of-network provider from June 26, 2019 through July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteriess.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the steroid testing rendered to the enrollee.
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 that procedure code 80327 has a status indicator of I.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that code 80327 (anabolic steroid testing) has a status indicator of I and is not valid for Medicare purposes. While this is true, this is based on the Physician Fee Schedule. Code 80327 is for laboratory services and was billed by a laboratory; therefore, the Clinical Lab Fee Schedule is binding. The Plan has not provided any Medicare rules or documentation to support that the services are not payable. Therefore, we decided that the Plan has to pay for the steroid testing rendered to the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee on January 21, 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 99239 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered to the enrollee on January 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) 95955 nerve conduction
studies 95908 and needle electromyography 95885 on June 20, 2019.
You asked the Plan to pay for the EEG, nerve conduction studies and needle electromyography. You say that
please review the documents as it pertains to medical necessity and provider documentation The Plan denied
your request. The Plan says the procedure codes were not supported in the medical records submitted.
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 codes 95955 26 59, 95908 26 59 and 95885 26 59 are an
EEG, nerve conduction studies and needle electromyography.
We asked our physician review 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 review says the records do
not support the services. Our review says that CPT code 95908 is not supported. The record states that pedicle
screws were stimulated. According to CPT rules, this is captured with another CPT code and should not be
reported with 95908. CPT code 95955 is not supported. The record states that continuous EEG was performed
for monitoring purposes. According to CPT rules, there is a more specific code for this procedure. CPT code
95885 is not supported. This is an add-on code that requires an approved primary procedure code. According to
the record, there is no approved primary code in this case.
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 EEG, nerve conduction studies and needle electromyography have not been
met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) 95955 nerve
conduction studies 95908 and needle electromyography 95885 on June 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance for a spinal injection (77003) provided on March 11, 2019.You asked the Plan to pay for the fluoroscopic guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 77003 was not billed with an appropriate primary procedure code.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 77003 is not supported in the medical record. Specifically, 77003 is an add-on code. The record does not indicate that 77003 was billed with an appropriate primary procedure code. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for a spinal injection (77003) provided on March 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee by the 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 procedure code 99239 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered to the enrollee by the provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an out of network provider.
You asked the Plan to pay for outpatient lab work. You say that you provided all the lab work that was requested. The Plan denied your request. The Plan says the enrollee was self-referred to the practice by her sister.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services rendered to the enrollee by the 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 procedure code 14060 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 10460 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less. We find that CPT code 10460 is not supported in the medical record. Specifically, there is no documentation of performance of an adjacent tissue transfer for the billed date of service. 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 outpatient surgical services rendered to the enrollee by the provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement provided on July 3, 2019 by an out of network provider.
You asked the Plan to pay for the debridement services. You say that the services were provided to the enrollee in good faith. You also say that you trusted the facility staff had obtained the necessary authorizations. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says that 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 referring provider is not a network provider either. 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 nail debridement provided on July 3, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the 5 radiation treatments, radiation consult, radiation treatment delivery, and stereoscopic x-ray guidance provided from July 24, 2019 to July 26, 2019 by the out of network provider.
You asked the Plan to pay for the radiation treatment delivery, and stereoscopic x-ray guidance. You say that The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee was not referred by their primary care physician 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 referring provider is not a network provider either. 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 5 radiation treatments, radiation consult, radiation treatment delivery, and stereoscopic x-ray guidance provided from July 24, 2019 to July 26, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation services (G6015 and G6002) provided from July 15, 2019 to July 18, 2019.
You asked the Plan to pay for radiation services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 radiation services (G6015 and G6002) provided from July 15, 2019 to July 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for paramedic intercept services provided on January 4, 2019.
You asked the Plan to pay for paramedic intercept services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the HCPCS ambulance mileage code is missing and the origin and destination modifier is missing.
The Plan must follow Medicare rules. The rules state that providers must bill with the correct codes. The claim is missing the mileage code and modifier. Based on this information, we decided that Medicare rules for coverage of the paramedic services have not been met. Therefore, we decided that the Plan does not have to pay for paramedic intercept services provided on January 4, 2019.