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

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 26, 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 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 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, 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 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the first hour of critical care services (99291) provided on June 10, 2018.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a critical care progress note for the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not indicate that critical care services were rendered on June 10, 2019. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the first hour of critical care services (99291) provided on June 10, 2018.
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 from August 17, 2019 to November 5, 2019.
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 batteries provided August 17, 2019 to November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, hospital outpatient clinic visit, and the electronic analysis of implanted neurostimulator pulse generator or transmitter provided from May 1, 2019 to June 14, 2019 by the out of network provider.You asked the Plan to pay forthe physician 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 self-directed 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 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, hospital outpatient clinic visit, and the electronic analysis of implanted neurostimulator pulse generator or transmitter provided from May 1, 2019 to June 14, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Eylea injections provided on June 27, 2019 August 1, 2019 and August 8, 2019.
You asked the Plan to pay for the Eylea injections. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.
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 and the referring provider are not network providers 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 Eylea injections provided on June 27, 2019 August 1, 2019 and August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99153 provided on May 16, 2019.
You asked the Plan to pay for CPT code 99153. You say that you would like the plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the rate, facility or non-facility that a physician
service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the
setting where the beneficiary received the face-to-face encounter with the physician, non-physician practitioner
(NPP) or other supplier.
We looked at the file and Medicare rules. The requested service was billed with POS 22, indicating the
outpatient hospital department in a hospital facility. This means that payment for the service in question would
have been included in the payment to the facility. Based on this information, we decided that Medicare rules
for coverage of CPT code 99153 have not been met. Therefore, we decided that the Plan does not have to pay
for CPT code 99153 provided on May 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on April 17, 2019, by an out-of-network provider.You asked the Plan to pay forthe services. You say that your company would be unable to obtain a separate authorization for your services, if the Plan did not approve the patient's admission and stay at the facility, as the plan was the patient's primary health insurance.The Plan denied your request. The Plan says the member does not have out-of-network benefits.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 non-urgent services are not authorized because the provider is a non-network provider with the member's health plan, and another non-network provider with the member's health plan referred the member for services The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on April 17, 2019, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided on September 6, 2019.You asked the Plan to pay for the chest x-ray. You say that the claim was not a duplicate, it was a repeat service.The Plan denied your request. The Plan says the claim was submitted as duplicate and did not properly denote a repeat service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 71045 is not supported in the medical record. Specifically, as billed, the claim is a duplicate of claim 820192531156429. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decidedthat the Plan does not have to pay fora chest x-ray (71045) provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) provided on August 19, 2019.
You asked the Plan to pay for the dental services. You say that you would like to appeal because your filling came out and the office needed to evaluate you. The Plan denied your request. The Plan says the benefit limit has been exceeded for this service.
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 health plan contract says this service is covered once every 6 months. Records show that you had received this same service on May 2, 2019. 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 limited oral exam (D0140) provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided by out of network provider on July 15, 2019 and July 22, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial as you were unaware that you needed an additional referral for the chiropractic services. The Plan denied your request. The Plan says the routine chiropractic services provided are not covered because they were not authorized, not emergent, and not urgently needed. At the time of service, you did not have a referral for the chiropractic care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that services not available from Plan Providers require prior authorization by the Medical Group for the services to be covered.
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 the chiropractic manipulative treatment (98941) provided by the out of network provider on July 15, 2019 and July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 26, 2019 through August 29, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you previously had a $250 copayment for an inpatient hospital stay. You say that the copayment is too high. 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 $275 per day, for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital. You have been asked to pay an $825 copayment for the inpatient stay. ($275/day x 3 days = $825). The inpatient stay falls within the "Inpatient hospital 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 the inpatient stay provided from August 26, 2019 through August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement rendered on May 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.The file shows that procedure code 77002 (fluoroscopic guidance) was billed with place of service code 22 for an outpatient hospital. The code was not billed with the required -26 modifier to allow for separatepayment of the professional component.Therefore, we decided that the Plan does not have to pay forthe fluoroscopic guidance for needle placement rendered on May 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing provided on December 11, 2018.You asked the Plan to pay forthe drug testing. The Plan denied your request. The Plan says the documentation did not include a valid physician order stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is only covered under certain medical indications. The file shows that the enrollee received definitive drug testing for 22 or more drug classes. We looked at the file and Medicare rules.A review of the medicalrecords shows that there were no aberrant behaviors found or suspected, and the enrollee was consistent with the prescribed regimen. There is no evidence that shows the test was individualized to identify 22or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe definitive drug testing provided to on December 11, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from August 19, 2019 to August 26, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from August 19, 2019 to August 26, 2019.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy techniques (97140) provided from July 29, 2019 to October 1, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the plan's denial as you have been suffering from back pain for twenty years. Additionally, you say that you have received immediate relief from the Graston therapy received. The Plan denied your request. The Plan says the services provided are not a covered benefit under your policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the manual therapy techniques (97140) provided July 29, 2019 to
October 1, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the chiropractic spinal manipulation. We decided that the Plan does not
have to pay for the non-chiropractic manipulation services.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan says that the
services are not covered.
We decided that the Plan has to pay for the chiropractic manipulation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The file shows that a claim for procedure code 98940 (chiropractic manipulative treatment (CMT); spinal, 1-2
regions) was billed for date of service May 10, 2019; May 13, 2019; and May 20, 2019. Therefore, we decided
that the Plan has to pay for the chiropractic manipulation of the spine rendered from May 10, 2019 to
May 20, 2019.
We also decided that the Plan does not have to pay for the non-chiropractic manipulation services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. The file shows that the
services at issue were billed with codes 97035 (ultrasound therapy), 97140 (manual therapy techniques), 97032
(electrical stimulation), and 99212 (office visit). Therefore, we decided that the Plan does not have to pay for
the non-chiropractic manipulation services rendered  from May 10, 2019 to May 20, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee can tolerate 3 hours of therapyThe Plan denied your request. The Plan says the enrollee does not require active and ongoing medical or therapeutic intervention of multiple therapy disciplines.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee's current level of function is ambulating with contact guard to minimal assist using a rolling walker, moderate assist for toileting and lower body dressing, and minimal assist for transfers. The complexity of the enrollee'snursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrolleerequired the intensity of an IRF stay with close physician or nursing supervision. The enrolleemay benefit and participate in additional physical and occupational therapy,but does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 26, 2019 by out of network provider.
You asked the Plan to pay for the office visit. You say that the service has been covered in the past and you believe the provider is in-network. The Plan denied your request. The Plan says the provider is out-of-network and there are in-network providers who can provide the same level of care.
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 February 26, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740) and pontic -
porcelain/ceramic (D6245) provided on July 31, 2019.
You asked the Plan to pay for the dental services. You say that the Plan should have processed the claim as one
single service instead of applying to each line of the claim. The Plan denied your request. The Plan says you
exhausted your benefit.
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.
There is a retainer crown, a pontic (an artificial tooth fixed to a dental bridge) in the middle, then another
retainer crown. Your claim from July 31, 2019, was billed with the following three separate charges:
-Tooth number 30, dental code D6245 (pontic- porcelain/ceramic) $1,347.00
-Tooth number 28, dental code D6740 (crown- porcelain/ceramic) $1,393.00
-Tooth number 31, dental code D6740 (crown- porcelain/ceramic) $1,393.00
The first two charges on this claim exhausted your $1,000.00 annual maximum for comprehensive dental care.
An allowed amount is not applied to dental services once your annual maximum has been used. As stated on
page 108 of your EOC, you are responsible for any amounts beyond your benefits limits. Therefore, we
decided that the Plan does not have to pay for retainer crown - porcelain/ceramic (D6740) and pontic -
porcelain/ceramic (D6245) provided on July 31, 2019.