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

We decided that the Plan does not have to pay for CPT code 99190 provided on July 25, 2019.You asked the Plan to pay forCPT code 99190. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 99190 is reimbursable when billed by the facility where the surgery was performed and is not payable under the physician fee schedule.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospitalfor services furnished to the beneficiary while an inpatient. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services should be included in the facility payment. Furthermore, CPT code 99190 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. The plan will accept a corrected claim billed by the facility where the services were performed. Based on this information, we decided that Medicare rules for coverage of CPT code 99190 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 99190 provided on July 25, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on December 5, 2018.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the $75 copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose toits 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 $75 copayment for out-of-network specialist services.You received specialist services from an out-of-network provider on December 5, 2018. Therefore, you are responsible to pay the $75 copayment. You have been asked to pay a $75 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on December 5, 2018.
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 October 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor and sensors.
You asked the Plan to pre-approve a continuous glucose monitor and sensors. You say that your doctor recommended a continuous glucose monitor to get a grip on how to treat your blood sugars and get them regulated. The Plan denied your request. The Plan says criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at this the file and Medicare rules. You are not insulin injecting three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor and sensors.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from June 18, 2019 to June 20, 2019.
You asked the Plan to pay for the medical services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of service.
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 medical services provided from June 18, 2019 to June 20, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care services (99222 and 99233) provided from August 15, 2019 to August 18, 2019.
You asked the Plan to pay for the hospital care services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from August 1, 2019 through August 18, 2019. The Plan states the provider needs to bill Original Medicare for the services rendered from August 15, 2019 through August 18, 2019.
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 hospital care services (99222 and 99233) provided from August 15, 2019 to August 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100 additional units of Botox injections.
You asked the Plan to pre-approve the additional Botox injections. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the additional Botox is not
medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 additional Botox injections. Our
reviewer says that based on the medical records provided the additional 100 units of Botox requested for this
enrollee are not medically appropriate and safe. Our physician reviewer found when treating one or more
indications, the maximum cumulative dose of Botox should generally not exceed 400 units in a 3-month
interval.
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 additional Botox injections have not been met. Therefore, we decided that
the Plan does not have to pre-approve 100 additional units of Botox injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram services provided on November 1, 2018.
You asked the Plan to pay for the electrocardiogram 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 a duplicate.
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 93010 is Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, this service is a duplicate of an allowed service submitted by another provider for the same service. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram services provided on November 1, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulmonary stress test (94618) provided on August 15, 2019.
You asked the Plan to pay for a pulmonary stress test. You say that the records support the service. The Plan denied your request. The Plan says the records do not contain documentation of this service being performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 94618 is pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed. 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 a pulmonary stress test. Our reviewer says that CPT code 94618 is not supported. Our physician reviewer found the record does not contain evidence that a pulmonary stress test was performed during this episode of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a pulmonary stress test have not been met. Therefore, we decided that the Plan does not have to pay for a pulmonary stress test (94618) provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Grab Bars, a Raised Toilet Seat, and a Shower Chair purchased from an out-of-network provider on April 1, 2019.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of the DME purchased. The Plan denied your request. The Plan says the DME was purchased from an out-of-network provider. The Plan states there were no phone calls to the plan prior to the purchasing the supplies to inquire if there are any in-network suppliers.
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 Grab Bars, a Raised Toilet Seat, and a Shower Chair purchased from an out-of-network provider on April 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on September 18, 2019.
You asked the Plan to pay for the outpatient services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 outpatient services provided on September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prothrombin time (85610) provided on September 6, 2019 by the out of network provider.
You asked the Plan to pay for prothrombin time. You say that you are appealing claim payment denial for services rendered to the Plan's member on date of service September 6, 2019. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 prothrombin time (85610) provided on September 6, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lovaza for the enrollee.
You asked the Plan to pre-approve Lovaza. You say that this is needed for the enrollee's heart disease. The Plan denied your request. The Plan says that this is not covered under 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 Lovaza for the enrollee.
Benefits for Lovaza 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 August 13, 2019 by the out of network provider. You asked the Plan to pay for an office visit. You say that you would like this claim to be reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained; therefore, payment has been correctly denied.
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 August 13, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 23, 2019 by the out of network provider.
You asked the Plan to pay for the office visit. 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.
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 office visit provided on August 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by out of network provider.
You asked the Plan to pay for a specialist office visit. You say that you did not know you needed prior authorization. You say that you cannot afford this amount. The Plan denied your request. The Plan says no prior authorization was obtained for the services that were provided.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 9, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing provided to enrollee on August 27, 2019.
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers; 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no evidence that shows the test was individualized to identify 22 or 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 for definitive drug testing provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 25, 2019 by out of network provider.
You asked the Plan to pay for the epidural injection (64483). You say that you were unaware of the enrollee's Medicare Advantage Plan. The Plan denied your request. The Plan says utilization of network providers when possible and available and authorization for out-of-network services is required.
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 April 25, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99497 provided on May 13, 2019.
You asked the Plan to pay for CPT code 99497. 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 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 medical record. Specifically, CPT code 99497 is a time based code. In order to bill CPT code 99497, the documentation must note that the first 30 minutes were face-to-face with the patient, family member(s), and/or surrogate for advance care planning. The progress note for May 13, 2019 does not note how much of the time spent was for advanced care planning. As such, the provided documentation does not support the billing of CPT code 99497. Based on this information, we decided that Medicare rules for coverage of CPT code 99497 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99497 provided on May 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided from June 25, 2019 through July 23, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME provided from June 25, 2019 through July 23, 2019. Each claim processed with $104.04 applying toward coinsurance. The claims are processing with 20% coinsurance for the DME item. 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 coinsurance for the DME provided from June 25, 2019 through July 23, 2019.