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

We decided that the Plan does not have to pay for the services rendered on September 25, 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 procedure codes 96138 and 96139 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 96138 is psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes. The definition of code 96139 is psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure). We find that CPT codes 96138 and 96139 are not supported in the medical record. Specifically, there is no documentation that neuropsychological testing as a series of tests was performed for the date of service at issue to support code 96138. Given that the primary code 96138 is not supported, the add-on code of 96139 is also not supported. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on September 25, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for dispensing fees (Q0513) provided to the enrollee on April 29, 2019.
You asked the Plan to pay for the dispensing fees (Q0513) provided to the enrollee on April 29, 2019. You say
that this claim should be paid. The Plan denied your request. The Plan says that while the inhalation solution
(J7699) will be paid, the dispensing fee (Q0513) was denied due to lack of proof of delivery.
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 Plans argument is not clear. If the Plan paid for the medication then clearly the dispensing fee,
which is an "action" would be paid as well. There would be no proof of delivery for an action. The Plan has not
made a clear case in its denial for code Q0513. Therefore, we decided that the Plan has to pay for dispensing
fees (Q0513) provided to the enrollee on April 29, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on January 30, 2020.
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. Medicare rules say that NGS is covered when specific criteria are met. We looked at the file and Medicare rules. There is no documentation to support that the testing at issue meets the Medicare criteria for coverage. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87641, 87798, and 87900
provided on October 23, 2019.
You asked the Plan to pay for the laboratory 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 87641, 87798, and 87900 are not supported in the medical record. Specifically, the
place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen
was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place
of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen
was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to
pay for the laboratory services coded 87641, 87798, and 87900 provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 28, 2020.
You asked the Plan to pay for the periodontal maintenance. The Plan denied your request. The Plan says that
this is not a covered benefit.
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
periodontal maintenance provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190) provided to the enrollee on December 23, 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 payment for this code is included in the payment to the facility.
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, payment for this code is included in the payment to the facility. 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 oxygenator assembly and operation services (CPT 99190) provided to the enrollee on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root planings and two local anesthesia services not in conjunction with operative or surgical procedures to be provided by an OON provider. You asked the Plan to pre-approve the periodontal scalings and root planings and local anesthesia services. The Plan denied your request. The Plan says you are not contracted with the enrollee's dental plan. 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 covered when they are received by an OON provider. There are in-network providers within the enrollee's time and distance standards set forth by Medicare to render the services in appeal. Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root planings and two local anesthesia services not in conjunction with operative or surgical procedures to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a Dental Cleaning (D1110) provided July 8, 2019 by a
provider who has opted out of Medicare.
You asked the Plan to pay for the dental cleaning. You say that the service should be covered. The Plan denied
your request. The Plan says the provider at issue has opted out of Medicare participation and is not eligible for
payment.
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. Dental services provided by a provider who has opted out of Medicare
are not eligible for coverage. Therefore, we decided that the Plan does not have to pay for a Dental Cleaning
(D1110) provided July 8, 2019 by a provider who has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on February 5, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you feel that the facility should not be considered an outpatient hospital facility and disagree with the charges. 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 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 $100 copayment for basic radiological services provided in an outpatient hospital facility. The record shows that you received an X-ray at an outpatient hospital facility. Therefore, you are responsible to pay the allowed amount of $77.44, which is less than the $100 copayment. You have been asked to pay $77.44 for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an X-ray provided on February 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic tests provided on January 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for diagnostic tests. 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.
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 diagnostic tests provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that the requested medication is necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria for a step therapy
exception has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Procrit. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the documentation submitted indicates
that you have no prior treatment, contraindication, or intolerance to Retacrit. The prescriber does not state why
the alternative Retacrit required by the Plan (1) would not be as effective for you as the requested drug; and/or
(2) would have adverse effects for you. Therefore, an exception to the Plan's step therapy criteria is not
supported.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to
pre-approve Procrit (J0885).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks.
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not
medically necessary.
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 injections. Our reviewer says that
the requested injections are not considered medically reasonable and necessary in this case. Our physician
reviewer found that this is an experimental/investigational procedure that is the subject of on-going clinical
trials. The enrollee is not enrolled in a clinical trial.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular nerve blocks.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit and wound
debridement provided on December 18, 2019.
You asked the Plan to waive the copayment for the outpatient clinic visit and wound debridement. You say that
you weren't informed that this was a surgical procedure. You say that you expected to be billed $15 for the
visit. The Plan denied your request. The Plan says the copayment 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 $75
copayment for surgery services at an in-network outpatient hospital.
You have been asked to pay a total of $75 for the outpatient clinic visit and wound debridement. The outpatient
clinic visit and wound debridement fall within the "Outpatient hospital services" benefit category. The records
show that wound debridement was provided during the clinic visit, which is considered a surgical service. 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 clinic visit and wound debridement provided
on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need the monitor to keep a record of your pressure so that your doctor can adjust your medications. The Plan denied your request. The Plan says that this is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on January 16, 2020.
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 procedure code 99231 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 99231 is Level 1 subsequent hospital care for evaluation and management of patient, including detailed history and physical examination, and medical decision making of low complexity - typical time 15 minutes. We find that CPT code 99231 is not supported in the medical record. Specifically, the records support only one unit of code 99231, which has already been paid by the Plan. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition supplies rendered from November 26, 2019 to December 2, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition supplies rendered from November 26, 2019 to December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 23, 2019. You asked the Plan to pay for the physician's 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 physician's services. 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 September 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulse oximeter. You asked the Plan to pre-approve a pulse oximeter (E0445). You say that you really need this item because of your health. The Plan denied your request. The Plan says pulse oximeters are not covered by Medicare or the Plan. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a pulse oximeter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core buildup, including any pins when required (D2950), restorative procedure (D2999), gum medication (D4381), and two applications of desensitizing resin for cervical and/or root surface (D9911 x2).
You asked the Plan to pre-approve the crown, core buildup, restorative procedure, gum medication, and applications of desensitizing resin. You say that you need two fillings with the desensitizing resin as well as a crown. You also say that these repairs are all needed. The Plan denied your request. The Plan says these services are not covered.
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 pre-approve a crown (D2740), core buildup, including any pins when required (D2950), restorative procedure (D2999), gum medication (D4381), and two applications of desensitizing resin for cervical and/or root surface (D9911 x2).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for eye injection (67500) provided on November 19, 2019.
You asked the Plan to pay for the eye injection. You say that you would like reconsideration as this service was rendered by separate providers. The Plan denied your request. The Plan says this surgery claim was submitted by a provider with an anesthesia specialty without applicable anesthesia codes.
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 67500 is not supported in the record. Specifically, the CPT code billed is a surgery service and this claim has been billed by a provider with an anesthesia specialty. Based on this information, we decided that Medicare rules for coverage of the eye injection have not been met. Therefore, we decided that the Plan does not have to pay for eye injection (67500) provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on December 26, 2019. You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. No medical records were received to support the diagnosis on the submitted order; therefore, the bill code cannot be supported. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on December 26, 2019.