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

We decided that the Plan does not have to pay for train of four testing (95999) provided on January 8, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment for this service is bundled into the payment of another procedure.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on January 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network provider.You asked the Plan to pay for the office visit (99214) and flu vaccine (90756). You say that the member has been with you for many years, prior to becoming a Plan member. The Plan denied your request. The Plan says the services were not urgent or emergent and there is no authorization on file.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 October 14, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies (95908) and an electroencephalogram (95955) provided on September 10, 2019.
You asked the Plan to pay for the needle electromyography, nerve conduction studies and electroencephalogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the codes billed are not supported in the medical record.
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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). We asked our coder 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 needle electromyography, nerve conduction studies and electroencephalogram. Our reviewer found CPT code 95885 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation that a nerve conduction study was performed, which is required in the description or CPT 95885 in order for CPT code 95885 to be eligible for billing and reimbursement consideration.
Our reviewer also found that CPT code 95908 does not meet criteria for billing or reimbursement consideration. The medical documentation submitted does not include documentation of a nerve conduction studies; 3-4 studies, therefore the service cannot be verified.
Our reviewer says that CPT code 95955 does not meet criteria for billing or reimbursement consideration. The medical records state "A full minute of baseline digital EEG recordings was taken. EEG's were bilaterally symmetric and normal in terms of frequency and amplitude." This documentation does not meet code definition criteria to indicate that an Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) was performed.
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 needle electromyography, nerve conduction studies and electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885), nerve conduction studies (95908) and an electroencephalogram (95955) provided on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on April 25, 2019 by the out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 oxygen concentrator provided on April 25, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on August 13, 2019.
You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a mammogram provided on August 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90853) provided from December 1, 2017 to December 31, 2017.
You asked the Plan to pay for psychotherapy services. You say that this was filed timely. The Plan denied your request. The Plan says this claim was filed more than a year after the services were provided.
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 psychotherapy services was not filed until July 9, 2019. The proof of delivery submitted with your appeal shows a delivery date of January 14, 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 psychotherapy services (90853) provided from December 1, 2017 to December 31, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on July 18, 2019.You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says the 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. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan hasto 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 did not pre-approve the servicesat 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 a hospital outpatient clinic visit provided on July 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided to the enrollee on August 13, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided to the enrollee on August 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not haveto pay foremergency services received on September 6, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis provider is non-Medicare-approved/certified freestanding emergency facility.The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that would require the plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay foremergency services received on September 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. 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 must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be 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 home health services. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found you need help with medication management, helping get out of bed, and cooking. The documentation does not support that you are homebound. There is no documentation in the medical records for the need for skilled services. There is not a physician order for skilled services. There is no documentation of your level of function. Therefore, you do 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834) provided from February 26, 2019 to April 30, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary, and you referred to the provider by the plan. The Plan denied your request. The Plan says the provider is ineligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors (LPC's) are not eligible for Medicare payment. We looked at the file and Medicare rules. This LPC is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services. have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90834) provided from February 26, 2019 to April 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 minutes of advance care planning (99497) provided on August 21, 2018.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of advance care planning including the explanation and discussion of advance directives with time spent.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that 30 minutes of advance care planning was rendered. Based on this information, we decided that Medicare rules for coverage of the advance care planning have not been met. Therefore, we decided that the Plan does not have to pay for 30 minutes of advance care planning (99497) provided on August 21, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory work provided on October 7, 2019.
You asked the Plan to waive the deductible for the laboratory work. You say that you needed the laboratory work done in order to get your prescriptions renewed. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that applies towards in-network laboratory services. The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards in-network laboratory services. The allowed amount for the laboratory work is $55.92. Therefore, $55.92 was applied to your deductible.
This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on October 7, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) and administration (90471) provided on June 27, 2019.
You asked the Plan to pay for a tetanus and diphtheria toxoids vaccine and administration. You say that you were told this would be covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of the enrollee's Part D plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus and diphtheria toxoids 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 and diphtheria toxoids vaccine and administration. Therefore, we decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) and administration (90471) provided on June 27, 2019.
Benefits for a tetanus and diphtheria toxoids vaccine and administration 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH which the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 7, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says there is no valid referral for this 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 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 laboratory services provided on March 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentsforthe observation stay and physical therapy evaluation provided on August 31, 2019 and September 1, 2019.You asked the Plan to waive the copayments forthe observation stay and physical therapy evaluation. You say that you did not have a specialist visit. You say that you are appealing the $40 balance.The Plandenied your request. The Plan says the copaymentsapplied 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 $350 copaymentfor each day of Medicare-covered observation services provided to you at an outpatient hospitaland a $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit.You have been asked to pay a $350 copayment for the observation stay and a $40 copayment for the physical therapy evaluation. The observation stay falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The physical therapy evaluation falls within the "Outpatient Rehabilitation Services" benefit category. The records show that the physical therapy evaluation was provided during the observation stay. 
This means thatyou 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 forthe observation stay and physical therapy evaluation provided on August 31, 2019 and September 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on September 19, 2019 by out of network providerYou asked the Plan to pay foran outpatient surgery. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for this 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 atissue 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 foran outpatient surgery provided on September 19, 2019 by out of network provider.