Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a prolonged visit (99354) and blood transfusion (36430) provided on July 10, 2019.You asked the Plan to pay for the prolonged visit and blood transfusion. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does 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 code 99354 is prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service). The CPT Code Manual definition of code 36430 is transfusion, blood or blood components.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the prolonged visit and blood transfusion. Our reviewer says that CPT code 99354 does not meet criteria for billing or reimbursement consideration. The documentation does not note the extra time spent with the member. Our reviewer found CPT code 36430 does not meet criteria for billing or reimbursement consideration. Payment is not made by the carrier when this procedure is performed by auxiliary staff in a free-standing facility.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 prolonged visit and blood transfusion have not been met.Therefore, we decided that the Plan does not have to pay for a prolonged visit (99354) and blood transfusion (36430) provided on July 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of teeth (dental extractions).
You asked the Plan to pre-approve the dental services. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve removal of teeth (dental extractions).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on November 12, 2019 by an OON provider.
You asked the Plan to pay for the crown. You say that you do not agree with the amount you are responsible for. You also say that the contract says the Plan will pay up to $1,000 and cover 50% of the approved cost. The Plan denied your request. The Plan says OON dental providers can bill you for the difference between their billed amount and the paid amount.
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 contract clearly states that you may pay more if you receive care from an OON provider. The records show that the Plan paid the in-network rate for this service, and you are responsible for the difference between the billed amount and amount the Plan paid because you were treated by an OON provider. Therefore, we decided that the Plan does not have to pay for the crown provided on November 12, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested nurse practitioner services.
You asked the Plan to pre-approve the nurse practitioner services. The Plan denied your request. The Plan says that the Plan does not cover non-emergency services by a non-contracted provider when a contracted provider can provide the services.
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 pre-approve 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 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested nurse practitioner services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services. You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says services with out-of-network providers are not approved unless the services are not available in the network or are 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 pre-approve 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 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on February 12, 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 separately payable.
The Plan must follow Medicare rules. Medicare rules say that follow-up visits are included in the global surgical package. We looked at the file and Medicare rules. The file shows that procedure code 99213 was billed within 90 days of the prior major surgical procedure on February 5, 2020. Payment for the office visit at issue is included in the global surgical package and has no separate payment. Therefore, we decided that the Plan does not have to pay for the office visit rendered on February 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from March 1, 2019 to March 18, 2019.You asked the Plan to pay forthe skilled nursing services. You say that you are looking for this claim to be processed for payment.The Plan denied your request. The Plan says the stay did not meet Medicare Part A coverage criteria. The Plan also says that the days appeared to be custodial, given the lack of progress the enrollee made earlier in her stay.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from March 1, 2019 to March 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness exam rendered on November 5, 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 exceeded the benefit limit.The Plan must follow Medicare rules. The rules say that Medicare covers an annual wellness exam once every 12 months.We looked at the file and Medicare rules. The file shows that you had an annual wellness exam on October 4, 2019 for which the Plan approved and paid. The annual wellness exam on November 5, 2019 was performed fewer than 12 months from your previously covered exam.Therefore, we decided that the Plan does not have to pay for the annual wellness exam rendered on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on January 13, 2020.
You asked the Plan to pay for the bitewings. You say that you believe the x-rays should be covered because you interpreted 12 consecutive months to mean January to January, and not necessarily date to date. The Plan denied your request. The Plan says bitewing x-rays are payable once in any period of 12 consecutive months.
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, bitewing x-rays are limited to every 12 months. The record shows that you received bitewing x-rays on January 14, 2019 and your bitewing x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hizentra solution billed for dates of service between October 20, 2019 and November 3, 2019.You asked the Planto pay for the Hizentra solution. You say that this should be covered due to medical necessity.The Plan denied your request. The Plan says there is no proof of delivery for the dates at issue.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. In this case, there is no documentation of proof of delivery for the billed dates of service. It appears that this was provided in one single delivery in September 2019. It is not appropriate to bill items for dates of service in which no item is delivered. The items delivered on September 19, 2019 should be billed for that date of service.Therefore, we decided that the Plan does not have to pay for the Hizentra solution billed for dates of service between October 20, 2019 and November 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services rendered on January 23, 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 codes 96413, 96411, and 96375 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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. The definition of code 96411 is chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure). The definition of code 96375 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure). We find that CPT codes 96413, 96411, and 96375 are not supported in the medical record. Specifically, there is no documentation of a start and stop time of chemotherapy administration to support code 96413. Given that primary procedure code 96413 is not supported, add-on codes 96411 and 96375 are 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 chemotherapy services rendered on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from February 21, 2020, to February 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 the enrollee by an out-of-network provider from February 21, 2020, to February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code G0481 provided on August 22, 2019.
You asked the Plan to pay for CPT code G0481. 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 G0481 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. We find that CPT code G0481 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 8-14 drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0481 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code G0481 provided on August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the GI endoscopy provided on December 4, 2019.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you were not informed of any outpatient hospital charge and that there is not a charge listed for an endoscopy. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the upper GI endoscopy is considered a surgical procedure.
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 upper GI endoscopy provided on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuplazid 34mg capsules.
You asked the Plan to pre-approve Nuplazid 34mg capsules. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Nuplazid 34mg capsules.
Benefits for Nuplazid 34mg capsules 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued CPAP rental.You asked the Plan to pre-approvecontinued CPAP rental. You say that you need to continue to use the CPAP.The Plan denied your request. The Plan says the compliance data received does not meet usage criteria for CPAP continuation. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you are not compliant with CPAP usage. Based on this information, we decided that Medicare rules for coverage of continued CPAP rental have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued CPAP rental.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on February 13, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that the representative at the dentist office assured you this would be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your insurance 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a shingles vaccine (90471 and 90750) provided on September 23, 2019.
You asked the Plan to pay for the shingles vaccine. You say that you would like reconsideration because you were told this service would be covered. The Plan denied your request. The Plan says vaccines covered under the Part D prescription drug benefit are not covered under your plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for a shingles vaccine (90471 and 90750) provided on September 23, 2019.
Benefits for the shingles vaccine 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 pre-approvethe requestedphysician's services.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says out of network providers are allowed only when the service is medically necessary but unavailable within the network or when an emergency.  As this is not the case there is no medical necessity for an out of network provider at the present time.Medicare rules say that plans can require enrollees to get care from network providers. The contract with thePlan says that the Plan has to pre-approve 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 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 6, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you were told you would not owe a 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 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 $20 copayment for labs. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic service 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 laboratory services provided on February 6, 2020.