Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult sized disposable incontinence product, protective underwear/pull-on, medium size, each (T4526).You asked the Plan to pre-approve incontinence supplies. You say that you need protective underwear because you are completely incontinent and unable to control your bowel movement.The Plan denied your request. The Plan says this item is not covered by the Plan or Medicare.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve adult sized disposable incontinence product, protective underwear/pull-on, medium size, each (T4526).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided on August 28, 2019.You asked the Plan to pay forthe ambulance service. You say that the transport was medically necessary.The Plan denied your request. The Plan says the enrollee was an inpatient at the time so the ambulance service is considered part of the inpatient admission and not separately payable.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. The record shows the enrollee was in inpatient status at the time of transport. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance service provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152, CPT 99153) provided to the enrollee on August 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes 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. Medicare rules also say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments. In this case, the CPT Code Manual definition of code 99152 is "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". 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 use of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of the presence of an independent trained observer to assist in
the monitoring of the patient's level of consciousness and physiological status. 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 CPT 99152 have not been met. Additionally, we find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 under the OPPS when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for the services (CPT 99152, CPT 99153) provided to the enrollee on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage (97035) and ultrasound therapy (97124) to be provided by a chiropractor.You asked the Plan to pre-approvethe massage and ultrasound therapy. You say that you have bad back spasms and the services provided by your medical doctor have not helped. The Plan denied your request. The Plan says ultrasound and massage done by a chiropractor are not covered benefits under Medicare.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve massage (97035) and ultrasound therapy (97124) to be provided by a chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fornegative pressure wound therapy provided on September 19, 2019.You asked the Plan to pay fornegative pressure wound therapy. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Medicare does not pay any provider or supplier other than the hospital for services furnished to the enrollee while an inpatient in the hospital.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.Records show that negative pressure wound therapy was used in a hospital.Payment for this service would have been included under the global facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay fornegative pressure wound therapy provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection (ESI).You asked the Plan to pre-approvethe ESI. You say that this should be approved.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 ESI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no adequate documentation to support the medical necessity of the requested procedure and its benefits. Moreover, the EMG did not reveal any cervical radiculopathy. A mild centraldisc herniation is not an indication for this procedure. There is no evidence that this procedure would alleviate the enrollee's pain.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the ESI have not been met.Therefore, we decided that the Plan does not have to pre-approvea cervical epidural steroid injection (ESI)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray exam of the knee, using 3 views (73562) provided on September 13, 2019.You asked the Plan to pay forthe 3 view X-ray. You say that the services were medically necessary and correctly billed.The Plan denied your request. The Plan says the records provided do not support the code 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 73562 is Radiologic Exam, Knee, 3 views .We find that CPT code 73562 is not supported in the medical record. Specifically, the records do not support multiple views. Based on this information, we decided that Medicare rules for coverage of the 3 view X-ray have not been met.Therefore, we decided that the Plan does not have to pay foran x-ray exam of the knee, using 3 views (73562) provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on August 28, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because you only had results read and were told you did 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 $50 copayment per visit with a specialist. You have been asked to pay a $50 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 for a specialist visit provided on August 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on May 18, 2019.You asked the Plan to pay for the molecular pathology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for molecular pathology services provided on May 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 16, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder-elbow-wrist-hand orthosis provided on May 6, 2019.You asked the Plan to pay forthe shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says there is no current medical record documenting medical necessity for the orthosis. 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. There are no medical records supporting medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the shoulder-elbow-wrist-hand orthosis (L3960) have not been met.Therefore, we decided that the Plan does not have to pay forthe shoulder-elbow-wrist-hand orthosis provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive (quantitative) drug testing for 1-7 drug classes provided on September 4, 2019.You asked the Plan to pay forthe definitive testing. You say that this testing should be paid.The Plan denied your request. The Plan says the order does not document the intent to perform this testing.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider.In this case, the lab orders do not clearly document intent to provide definitive testing. The order/results appear to reflect a general presumptive screening, which was paid on original claim processing.Therefore, we decided that the Plan does not have to pay forthe definitive (quantitative) drug testing for 1-7 drug classes provided on September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that LTACH should be covered.The Plandenied your request. The Plansaysthese services can be provided in the current facility.The Plan must follow Medicare rules. Therules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH for acute sepsis and chronic perineal wounds. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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 LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit for the evaluation and management of an established patient (99335) provided on July 11, 2019 by an out of network (OON) provider.You asked the Plan to pay fora domiciliary or rest home visit. You say that you submitted additional documentation requested to review for the maximum allowed amount.The Plan denied your request. The Plan says the medical records submitted do not meet urgent/emergent criteria. There was no documentation of prior authorization. The same service is 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 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 fora domiciliary or rest home visit for the evaluation and management of an established patient (99335) provided on July 11, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 10, 2019 and June 17, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no valid referral for this service.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 10, 2019 and June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 36430 provided on November 1, 2019.You asked the Plan to pay forCPT code 36430. 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 as billed.The Plan must follow Medicare rules. Medicare rulessay that providers must report services correctly.We looked at the file and Medicare rules. In this case, the enrollee received services (CPT code 36430) while in an ambulatory surgical center, an outpatient setting on November 1, 2019. Per Medicare payment guidelines, CPT code 36430 has a PC/TC indicator of 5 and payment may not be made for this code when provided to patients in a hospital outpatient department.Therefore, we decided that the Plan does not have to pay forCPT code 36430 provided on November 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 7, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you did not receive any additional services 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 $40 copayment for each basic imaging service. The medical records show that you had an ultrasound on October 7, 2019. Therefore, you are responsible to pay the allowed amount of $12.54, which is less than the $40 copayment. You have been asked to pay $12.54 for an ultrasound. An ultrasound 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 foran ultrasound provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on March 29, 2019.You asked the Plan to pay forthe hearing aids. You say that you were not aware that you could not use any doctor. You would have thought the doctor's office would have let you know that your hearing aids would not be covered by your insurance.The Plan denied your request. The Plan says hearingaids are not covered when not purchased through the designated vendor.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rulesapply in this case. The Plan pays for hearing aids only when purchased through approved services. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forhearing aids purchased on March 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on February 20, 2019.You asked the Plan to pay forthe train of four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says train of four monitoring is  considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoring.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 95999 is not supported in the record. Specifically, train of four monitoring is bundled with the approved neuromonitoring service and is not separately reportable. Based on thisinformation, we decided that Medicare rules for coverage of the train of four monitoring have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four monitoring (95999) provided on February 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyeglass frames(V2020) bifocal lenses (V2203) progressive lenses (V2871) provided on July 8, 2019.You asked the Plan to pay forthe vision services. You say that you did not get progressive lens. You only got reading glasses and cannot see out of them. You could have got some as good as or better at the dollar tree.The Plan denied your request. The Plan says the maximum benefit allowed has been exceeded.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 any amount over the plan's allowed $200 benefit for supplemental eyewear. You have been asked to pay $175. The plan has a $200 eyewear benefit. The provider billed $375 and the plan paid $200. The amount over the plan benefit is your responsibility. for the vision services. the vision services fall within the Vision 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 pay forthe eyeglass frames(V2020) bifocal lenses (V2203) progressive lenses (V2871) provided on July 8, 2019.