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

We decided that the Plan does not have to pay for the home infusion therapy rendered from September 12, 2019 to September 19, 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 from September 12, 2019 to September 19, 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 medical services provided on December 27, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for paid. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider,  is also out-of-network. The Plan says that the member's primary care physician did not refer the enrollee.
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 December 27, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 alveoloplasties in conjunction with extractions, 2 removals of torus mandibularis, inhalation of nitrous oxide/analgesia, and 3 extractions provided on July 10, 2019.
You asked the Plan to pay for the alveoloplasties, removal of torus mandibularis, inhalation of nitrous oxide/analgesia, and extractions. You say that you feel that the surgery had to be done for the enrollee's wellbeing and staying healthy. The Plan denied your request. The Plan says these services are not covered under the enrollee's contract under any circumstances.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 4 alveoloplasties in conjunction with extractions, 2 removals of torus mandibularis, inhalation of nitrous oxide/analgesia, and 3 extractions provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on April 12, 2019.
You asked the Plan to pay for the moderate sedation 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 codes 99152 and 99153 are not supported in the medical record. Specifically, code 99152 represents Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra service time, patient age 5 years or older. The documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Also, the documentation submitted and the claim form indicate that procedure 99153 was performed in a facility place of 22. Payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 and 99153 provided on April 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 sessions of cardiac rehabilitation without monitoring, and 12 sessions of cardiac rehabilitation with monitoring provided from July 2, 2019 to July 31, 2019 by the out of network provider.You asked the Plan to pay for the outpatient cardiac rehab 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 whocan 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 forthe 2 sessions of cardiac rehabilitation without monitoring, and 12 sessions of cardiac rehabilitation with monitoring provided from July 2, 2019 to July 31, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 4, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says vision
services require prior authorization prior to the services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 physician's services provided on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 11, 2019.
You asked the Plan to pay for the physician service. You say that the provider's office is unsure of the requirement for a referral. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. 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. You are not a network provider with the Plan. 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 provided on April 11, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered to the enrollee from April 4, 2019 to April 30, 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 enrollee was on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered to the enrollee from April 4, 2019 to April 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on August 6, 2019.You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger 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 separately payable.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 99190 is Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided while the enrollee was inpatient, therefore, payment for these services are included in the DRG payment to the facility. Payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met.Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on August 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (96374)
provided August 12, 2019 by the Provider
You asked the Plan to waive the copayment for the emergency room services. You say that you never had to
pay a copayment before and the copayment should be waived. The Plan denied your request. The Plan says the
correct cost-share has been applied.
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 $120
copayment for Emergency Care.
You have been asked to pay a $120 copayment for the emergency room services. The emergency room services
fall within the Emergency 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
Emergency Room Services (96374) provided August 12, 2019 by the Provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 51785 provided on April 29, 2019.You asked the Plan to pay for CPT code 51785. 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 providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 51785 is Needle electromyography studies (EMG) of anal or urethral sphincter, any technique.We find that CPT code 51785 is not supported in the medical record. Specifically, CPT code 51785 is not documented in the medical records submitted to verify if the services were billed correctly. Based on this information, we decided that Medicare rules for coverage of CPT code 51785 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 51785 provided on April 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on September 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says services are not
covered with out-of-network providers.
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on
September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a typhoid vaccine (90691), a hepatitis A and hepatitis B vaccine (90636), a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715), and a measles, mumps and rubella virus vaccine (90707) provided on August 15, 2019.You asked the Plan to pay for vaccines. You say that you were told these vaccines would be covered.The Plan denied your request. The Plan says these vaccines are the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to vaccines.Therefore, we decided that the Plan does not have to pay fora typhoid vaccine (90691), a hepatitis A and hepatitis B vaccine (90636), a tetanus, diphtheria toxoids and acellular pertussis vaccine (90715), and a measles, mumps and rubella virus vaccine (90707) provided on August 15, 2019.Benefits for vaccines may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a home blood glucose monitor (E0607), blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and spring-powered device for lancet (A4258) provided from June 20, 2019 to September 8, 2019.
You asked the Plan to pay for the home blood glucose monitor, blood glucose test or reagent strips, lancets, calibrator solution / chips, and spring-powered device for lancet. You say that the items were provided and payment should be rendered. The Plan denied your request. The Plan says the documentation provided did not include a valid proof of delivery. Therefore, coverage criteria has not been met.
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 physician order and 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. Specifically, the delivery ticket is missing a valid signature. Therefore, we decided that the Plan does not have to pay for a home blood glucose monitor (E0607), blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and spring-powered device for lancet (A4258) provided from June 20, 2019 to September 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology consultation at a contracted tertiary facility.
You asked the Plan to pre-approve the dermatology consultation at the facility. You say that the enrollee is currently being treated for high-risk myelodysplastic syndrome. You say that the enrollee has active disease and is actively receiving chemotherapy. You say that the enrollee is at a high risk for secondary malignancies, opportunistic infections, and leukemic involvement of organs including the skin. You say that the enrollee's skin lesions should be evaluated at the facility so that specialized testing and/or treatment for an infectious or malignant etiology may be done there if needed. The Plan denied your request. The Plan says the enrollee does not meet the tertiary care guidelines for the dermatology services requested. The plan says that the physician is able to safely and effectively treat the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the dermatology consultation at the facility. Our reviewer says that it is not medically reasonable and necessary for the enrollee to receive the requested care at a tertiary facility. Our physician reviewer found the enrollee is treated for meylodysplastic syndrome. Our physician reviewer found that the enrollee is receiving Jakafi and decitabine for treatment. Our physician reviewer found that the enrollee has a lesion behind his ear which has been evaluated by dermatology with a diagnosis of eosinophilic cellulitis. Our physician reviewer found that the enrollee's oncologist requested that the dermatology consultation be performed at the facility so specialized testing can be performed if needed. Our physician reviewer found that a second opinion can be provided at a non-tertiary facility. Our physician reviewer found that there is no information submitted that tertiary care is necessary at this time. Our physician reviewer found that a second opinion can be rendered by a dermatologist at a non-tertiary level of care, and if tertiary care services are needed, a request and rationale for those services can be provided by the evaluating dermatologist. 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 dermatology consultation at the facility have not been met. Therefore, we decided that the Plan does not have to pre-approve a dermatology consultation at the contracted tertiary facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services for a domiciliary/rest home visit provided on September 6, 2019.You asked the Plan to pay for the physician's 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 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 physician services for a domiciliary/rest home visit provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external ambulatory infusion pump.
You asked the Plan to pre-approve an external ambulatory infusion pump. The Plan denied your request. The Plan says that you do not meet the criterion of having a glycosylated hemoglobin level of greater than 7.
The Plan follows Medicare rules. Medicare rules say that external infusion pumps are covered if the above criteria have been met.
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 an external ambulatory infusion pump. Our reviewer says that an external ambulatory infusion pump is not medically reasonable and necessary in this case. The provided medical records do not indicate that the enrollee meets the criteria for an external ambulatory infusion pump. Our physician reviewer found that your condition does not meet Medicare criteria for this item. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an external ambulatory infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory infusion pump.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on July 26, 2019.You asked the Plan to pay for the psychotherapy services. 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 psychotherapy services provided on July 26, 2019.