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

We decided that the Plan does not have to pay forthe high osmolar contrast material coded Q9958 provided on December 13, 2019.You asked the Plan to pay forthe high osmolar contrast material. 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.In this case, the CPT Code Manual definition of code Q9958 is high osmolar contrast material, up to 149 mg/ml iodine concentration, per ml.We find that CPT code Q9958 is not supported in the medical record. Specifically, as the single use vial or single use package for the billed NDC total billable units is 3000 units per NDC and only 300 total units were billed, per the above Medicare guidelines we find the Medicare rule for payment of HCPCS code Q9958has not been met. Based on this information, we decided that Medicare rules for coverage of the high osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay forthe high osmolar contrast material coded Q9958 provided on December 13, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CFTR, CYP2CP, F, F5, MTHFR, SLCO1B1, and VKORC1 testing provided on September 11, 2019.
You asked the Plan to pay for the CFTR, CYP2CP, F, F5, MTHFR, SLCO1B1, and VKORC1 testing. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The CFTR, CYP2CP, F, F5, MTHFR, SLCO1B1, and VKORC1 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the CFTR, CYP2CP, F, F5, MTHFR, SLCO1B1, and VKORC1 testing provided on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo.
You asked the Plan to pre-approve the Forteo. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not a covered benefit under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Forteo.
Benefits for the Forteo 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room services (99285, 93010) provided May 1, 2014.
You asked the Plan to pay for the Emergency Room services. You say that the claim was filed timely. The Plan denied your request. The Plan says the claim was not received by the plan within 12 months or 1 calendar year from the date when the services were rendered.
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 Emergency Room services was not filed until December 3, 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 Emergency Room services (99285, 93010) provided May 1, 2014.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for open or percutaneous transcatheter placement services coded 37215, selective catheter placement services coded 36222, and selective catheter placement services coded 36224
You asked the Plan to pay for open or percutaneous transcatheter placement services and the selective catheter placement 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. We find that CPT code 37215, 36222, and 36224 is not supported in the medical record. Specifically, the operative report did not include documentation of an open or percutaneous transcatheter placement of an intravascular stent(s) into the cervical carotid artery, including angioplasty, when performed, and radiological supervision and interpretation, with distal embolic protection; therefore, code 97215 cannot be verified.
The operative report did not include documentation of a selective catheter placement, into unilateral common carotid or innominate artery, using any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, including angiography of the cervicocerebral arch, when performed; therefore, code 36222 cannot be verified.
The operative report did not include documentation of a selective catheter placement, into unilateral internal carotid artery, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, including angiography of the extracranial carotid and cervicocerebral arch, when performed; therefore, code 36224 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of open or percutaneous transcatheter placement services and the selective catheter placement services have not been met. Therefore, we decided that the Plan does not have to pay for open or percutaneous transcatheter placement services coded 37215, selective catheter placement services coded 36222, and selective catheter placement services coded 36224
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99215) provided on
November 26, 2019.
You asked the Plan to issue reimbursement for the office visit. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not
a covered benefit under your contractual 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 service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to issue reimbursement for the office visit (99215) provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 to March 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visits. You say that you would like reconsideration because you would like to continue seeing this provider. The Plan denied your request. The Plan says the rendering provider is non-par and there is no evidence that these visits were 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 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 January 28, 2020 to March 10, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on March 13, 2020 by an out of network (OON) provider.You asked the Plan to pay for outpatient mental health services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on March 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says your needs can be met at a different level of care.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program.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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Provenge.
You asked the Plan to pre-approve Provenge. You say that Provenge is medically necessary. The Plan denied your request. The Plan says Provenge is not FDA approved for the enrollee's diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Provenge. Our reviewer says that Provenge is not medically necessary in this case. Our physician reviewer found Provenge is FDA approved for the treatment of asymptomatic or minimally symptomatic metastatic hormone-refractory prostate cancer. The enrollee's diagnosis does not fit this criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Provenge have not been met. Therefore, we decided that the Plan does not have to pre-approve Provenge.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87633 provided on March 21, 2020.
You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that code 87633 is non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87633 provided on March 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing provided on February 13, 2020.
You asked the Plan to pay for the testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310,
81311, 81314, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported in the medical
record. Specifically, requires the use of CPT 81479 and the appropriate identifier entered
adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to
pay for the testing provided on February 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit services coded 99285 provided on January 29, 2020.You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed were billed incorrectly.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 99285 is not supported in the medical record. Specifically, this code was billed with a diagnosis that is a secondary only diagnosis code. This diagnosis code can not be used as the primary, first-listed or principal diagnosis for any procedure or service. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met.Therefore, we decided that the Plan does not have to pay for the emergency department visit services coded 99285 provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and intraoral xrays
(D0210) provided on March 11, 2020.
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and intraoral x-rays (D0210). You
say that the book does not show a frequency of 3 years. You say that the dentist said that you were approved
for everything. The Plan denied your request. The Plan says a comprehensive oral evaluation and intraoral xrays
are only allowed one procedure every three plan years.
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 Plan also has a maximum benefit
of one comprehensive oral evaluation and one intraoral x-ray every three plan years. The Plan paid for a
comprehensive oral evaluation and intraoral x-rays on January 21, 2019, which exhausted your benefit.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and
intraoral x-rays (D0210) provided on March 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermediate wound repair (12041) provided August 29, 2019.You asked the Plan to pay for the wound repair. You say that the services were medically necessary.The Plan denied your request. The Plan says the records do not support the code 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 12041 is Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less.We find that CPT code 12041 is not supported in the medical record. Specifically, the provided records do not note that an intermediate wound repair was performed. Based on this information, we decided that Medicare rules for coverage of the wound repair have not been met.Therefore, we decided that the Plan does not have to pay for an intermediate wound repair (12041) provided August 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies and oxygen used during ambulance transport provided on December 8, 2019.
You asked the Plan to pay for the supplies and oxygen. The Plan denied your request. The Plan says that supplies and oxygen are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and does not include a separate payment for items and services furnished under the ambulance benefit. Therefore, we decided that the Plan does not have to pay for the supplies and oxygen used during ambulance transport provided on December 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 2, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for transthoracic echocardiography (TTE). You say that you were told that
authorization was not required. The Plan denied your request. The Plan says the denial of payment for this
service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for
service.
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 March 2, 2020
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on November 19, 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 the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician).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 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found Medicare rules state that if a lab bills laboratory services to Medicare, there must be a signed order from the treating physician (or a progress note to support the intent to order) and documentation to support the medical necessity of the ordered services. In this case, the case file contains only a signed Custom Toxicology Profile order form. There is no evidence that the UDT was tailored to the enrollee's medical condition. The documentation does not support the coding of G0483, or that the UDT was medically reasonable and necessary for the enrollee 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 services have not been met.Therefore, we decided that the Plan does not have to pay for[drug testing services (HCPCS G0483) provided to the enrollee on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 15, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the oxygen concentrator (E1390). You say that you would like reconsideration
because this supply is medically necessary. The Plan denied your request. The Plan says utilization of network
providers is required 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 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 March 15, 2020
by an out of network (OON) provider.