Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health care provided on August 19, 2019.You asked the Plan to waive the copayment for the outpatient mental health care. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient mental health care on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.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 $40 copayment for Outpatient mental health care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient mental health care on August 19,2019. You have been asked to pay a $40 copayment for the outpatient mental health care. The outpatient mental health care falls within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the outpatient mental health care provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe platelet rich plasma injections (0232T) provided on September 20, 2019.You asked the Plan to pay forthe platelet rich plasma injections. 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 effective August 2, 2012, upon reconsideration, The Centers for Medicare and Medicaid Services (CMS) has determined that platelet-rich plasma (PRP) -an autologous blood-derived product, will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds. The rules also say that Category III CPT Code, 0232T, is considered not medically necessary.We looked at the file and Medicare rules. The file shows that the platelet rich plasma injections were provided to treat chronic severe bilateral knee pain. Medicare excludes coverage of platelet rich plasma injections for this condition. Furthermore, Medicare excludes coverage of CPT code 0232T as not medically necessary. Based on this information, we decided that Medicare rules for coverage of the platelet rich plasma injections have not been met.Therefore, we decided that the Plan does not have to pay forthe platelet rich plasma injections (0232T) provided on September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 99220 provided on July 11, 2019.You asked the Plan to pay forCPT code 99220. 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. We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code.Therefore, we decided that the Plan does not have to pay forCPT code 99220 provided on July 11, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care, per day, for the evaluation and management of a patient (99309) provided on February 27, 2019 by out-of-network provider, "the provider".You asked the Plan to pay forthe subsequent nursing facility care. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria has not been met.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 care that cannot be provided by network providers."the provider" is not a network provider with the Plan. 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 subsequent nursing facility care. Our reviewer says that the services were not medically necessary. Our physician reviewer found that although the enrollee may have received benefit from skilled services in a skilled nursing facility (SNF) the services do not reveal that an out-of-network provider was urgently needed or emergent in nature. The enrollee had physician oversight and speech therapy (ST), physical therapy (PT), and occupational therapy (OT) in a SNF. The services and medical records submitted do not indicate that the enrollee had an urgent or emergent medical need that required admission to an out of network facility.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 subsequent nursing facility care have not been met. 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pay for the subsequent nursing facility care.Therefore, we decided that the Plan does not have to pay forsubsequent nursing facility care, per day, for the evaluation and management of a patient (99309) provided on February 27, 2019 by out-of-network provider, "the provider".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital services provided from July 10, 2019 to July 11, 2019 by "the hospital".You asked the Plan to pay forinpatient hospital services. You say that the services were medically necessary.The Plan denied your request. The Plan says the care received could have been provided at an observation level of care, therefore coverage criteria for inpatient admission has not been met.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required. 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 inpatient hospital services. Our reviewer says that the services were not medically necessary. Our physician reviewer found based on the medical records provided the enrollee could have been managed at an observation level of care and in-patient admission from July 10, 2019 to July 11, 2019 does not appear to have been medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital services provided from July 10, 2019 to July 11, 2019 by "the hospital".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95999 provided on September 17, 2018.You asked the Plan to pay forCPT code 95999. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says CPT code 95999 is 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train for four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met.Therefore, we decided that the Plan does nothave to pay forCPT code 95999 provided on September 17, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of area office visit (99214) and blood work (83036) provided on August 12, 2019.You asked the Plan to pay for the out of area office visit (99214) and blood work (83036). You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out of area care.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at the file and Medicare rules. The files shows that you went to see this provider on August 12, 2019 for a routine office visit and blood work. The file does not show that these services were urgently needed services due to an unforeseen illness or condition. Based on this information, we decided that Medicare rules for coverage of the out of area office visit (99214) and blood work (83036) have not been met.Therefore, we decided that the Plan does not have to pay for the out of area office visit (99214) and blood work (83036) provided on August 12, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation of the pelvic x-ray provided on August 21, 2019.You asked the Plan to pay for the x-ray interpretation. You say that the enrollee had multiple x-ray exams on the same date for which separate radiology reports were generated. These are separately payable services.The Plan denied your request. The Plan says that since payment was made for the reading of a hip x-ray on 8/21/2019, payment cannot be made for a pelvic x-ray as well.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan states that this x-ray interpretation cannot be separately paid as it was billed on the same date as code 73501. Although these codes do have a Column 1/Column 2 relationship, these were provided by two different interpreting radiologist. The records clearly indicate that the pelvic x-ray was taken at 5:55PM and the hip x-ray coded as 73501 was taken at 1:51PM. As these are clearly separate and distinct services, both are payable.Therefore, we decided that the Plan has to pay for the interpretation of the pelvic x-ray provided on August 21, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (an MRI) (70551) provided on July 31, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you are being charged double for your copayment. You feel your copayment should be reduced to $75 to reduce the hardship on you. The Plan denied your request. The Plan says outpatient hospital services have a $225 copayment which includes diagnostic radiology other than CT scans.
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 $225 copayment for outpatient hospital services. You have been asked to pay a $211.26 copayment for an MRI. This service falls within the outpatient hospital services benefit category. On the same date of service, July 31, 2019, you received 3 CPT codes: 77067 (a screening mammogram), 77063 (a digital screening of the breast), and 70551 (an MRI). The total amount billed for 77067 and 77063 equals $270, which you were not charged a copayment. The allowable amount for 70551 equals $211.26 which is less than the copayment of $225. 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 magnetic resonance imaging (an MRI) (70551) provided on July 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 24, 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 he records do not support the service 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 the denied codes is:CPT 94727:Gas dilution or washout for determination of lung volumes and, when performed, distribution of ventilation and closing volumes CPT 92537:Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) We asked our coding 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 coded correctly. Our coding reviewer found the medical record does not contain evidence that the procedures described by CPT codes 92537 and 94727 were performed during this episode of care. These codes cannot be verified.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 services have not been met.Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on June
11, 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 records do not support the services as coded.
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 the denied services is:
CPT 99152:
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 intraservice time, patient age 5 years or older.
CPT 99153:
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; each additional 15 minutes intraservice time.
We asked our coding 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 coded correctly. Our coding reviewer found CPT codes 99152 and 99153
are not supported by the medical records submitted. The documentation does not contain the amount of time
spent performing moderate sedation, or that a trained, independent observer was present during the duration of
the moderate sedation. These codes cannot be verified.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for moderate sedation services provided to the enrollee on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 24, 2019.
You asked the Plan to pay for the office visit. You say that this claim was billed with modifier -GW to notify that this is not related to hospice care. The Plan denied your request. The Plan says non-hospice related services are payable by the Original Medicare contractor until the end of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 24, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit provided on July 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on March 19, 2019.You asked the Plan to pay for the genetic testing. 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 a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 19, 2019 by out of
network provider.
You asked the Plan to pay for physician services. You say that it is not the doctor's fault that the facility failed
to get preauthorization for this patient. The Plan denied your request. The Plan says no prior authorization was
obtained; therefore, the claim has been denied for payment.
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 July 19, 2019 by
out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on March 21, to the enrollee by out-of-network provider. You asked the Plan to pay for the out-of-network services. You say that you have taken over the enrollee's full care.The Plan denied your request. The Plan says the utilization of network providers, and authorization for certain 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 home visit provided on March 21, to the enrollee by out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered to you on July 29, 2019.You asked the Plan to waive the copayment for these services. You say that the services were an annual wellness visit.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment per visit for in-network primary care physician (PCP) visit for Medicare-covered services. Review of the file shows that you received an office visit on July 29, 2019. These services fall outside of the scope of an annual wellness visit. You have been asked to pay a $25 copayment for these services. These services fall within the in-network primary care physician (PCP) visit for Medicare-covered services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit rendered to you on July 29, 2019.