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

We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 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 G0482 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 G0482 is definitive drug testing, 15-21 drug classes. We find that CPT code G0482 is not supported in the medical record. Specifically, there is no documentation of testing of 15-21 drug classes.
The rules say that testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately reportable.
The provider submitted a claim for procedure codes 82565 and 84315. These tests were urine specimens utilized for drug testing. 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 laboratory services rendered on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 29, 2020.
You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit and you should not owe a copayment just because you discussed a condition. 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 $30 copayment for primary care visits. The medical records show that you received services beyond an annual wellness visit on January 29, 2020. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for an office visit. An office 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 an office visit provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 8, 2020 by a nonparticipating
provider.
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 were rendered by a non-participating provider without 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 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 May 8, 2020 by
a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 27, 2020.You asked the Plan to waive the copayment for the laboratory work. You say that the cost of routine bloodwork for your yearly check-up at an in-network laboratory is no cost for you. 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 $35 copayment for laboratory services at an in-network outpatient hospital. You have been asked to pay a $35 copayment for the laboratory work. The laboratory work 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 the laboratory work provided on January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisting living facility care (99487) provided on March 31, 2020.You asked the Plan to pay for the assisting living facility care. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent and there were network providers available.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 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 forthe assisting living facility care (99487) provided on March 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that on the date of service you fell and called 911 for help. You say that the paramedics came to you but they did not transport you to the hospital. You stated that you want to appeal the Plan's denial because you cannot afford the bill and you asked the Plan to consider covering it.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 20, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex Intravenous Immunoglobulin (IVIG) therapy.You asked the Plan to pre-approve Gamunex Intravenous Immunoglobulin (IVIG) therapy. You say that the requested Gamunex IVIG therapy is medically necessary.The Plan denied your request. The Plan says the enrollee does not have a covered indication for Gamunex IVIG therapy.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 Gamunex Intravenous Immunoglobulin (IVIG) therapy. Our reviewer says that the enrollee does not have a covered indication for Gamunex IVIG therapy. Our physician reviewer found the enrollee has a diagnosis of neuromyelitis optica (NMO). She is noted to have anti-MOG antibodies. The enrollee's diagnosis of anti-MOG NMO is not one for which the LCD supports the use of IVIG. There is otherwise not a body of literature available that permits conclusions on the efficacy of IVIG in MOG-NMOSD. The majority of the literature on the enrollee's condition/diagnosis and related syndromes are largely limited to case reports, series and cohort studies. A paper reported that 7 subjects with various anti-MOG syndromes were evaluated. The results did not readily demonstrate efficacy, noting "Three patients had six relapses while on adequate treatment with IVIG. Three out of seven (43%) experienced treatment failure". Another paper cited by the provider by Hacohen et al (2018) was mostly an evaluation of the condition in the pediatric population, so these findings cannot readily be translated into the adult population. Given the limitations from the published literature in this setting it cannot be concluded that the use of IVIG would be of demonstrated benefit in the management of this enrollee's condition. Particularly, based on the published evidence to date from adult studies it cannot be concluded that IVIG would be an effective treatment in preventing further possible relapses of the enrollee's condition/syndrome.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gamunex Intravenous Immunoglobulin (IVIG) therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve Gamunex Intravenous Immunoglobulin (IVIG) therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram and ultrasound provided
on February 6, 2020.
You asked the Plan to waive the copayment for the mammogram and the ultrasound. You say that you had to
go in for a repeat mammogram and sonogram. You say you will not be paying this bill. 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 $110
copayment for basic radiological services at an in-network outpatient hospital.
You have been asked to pay a $110 copayment for the mammogram and the ultrasound. The mammogram and
the ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The record shows you received a screening mammogram on February 4, 2020.
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 mammogram and ultrasound provided on February 6,
2020.
Your complaint that this billing practice is a scam is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure services provided on December 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the therapeutic procedure 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 a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure services provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a oxygen concentrator and home oxygen to be provided
by an out of network (OON) provider.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says medically
necessary care is available in network and that the provider has the requested oxygen concentrator.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a oxygen concentrator and home oxygen to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services (CPT 99354 and CPT 36430) provided to the enrollee on August 5, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is:CPT 36430:Transfusion, blood or blood components,CPT 99354: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) 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 supported by the medical records submitted. Our coding reviewer found documentation of a prolonged evaluation and management or psychotherapy service was not included.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 forphysician services (CPT 99354 and CPT 36430) provided to the enrollee on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).You asked the Plan to pre-approvetotal electric hospital bed. You say that the electric bed is extremely necessary to help your caretaker get you into bed. Your caretaker has to physically lift you from your chair into your bed without anyhelp.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on August 7, 2018.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 claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until March 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe office visit rendered on August 7, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve raised toilet seat (E0244).
You asked the Plan to pre-approve the raised toilet seat. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 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 does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve raised toilet seat (E0244).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for an electroencephalogram (EEG) with an
out-of-network in-home provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the plan's participating hospitals and providers have quality assurance measures in place
to prevent spreading of COVID-19.
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 referral. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found both ambulatory and attended EEGs have clinical benefits in the diagnosis/classification of epilepsy. In
this case, the provision of an AEEG by an out-of-network provider would exceed the enrollee's current medical
needs (as a similar study could be provided on an in-network basis). Furthermore, given that there is a
suspicion for possible pseudoseizures in this case the enrollee may further benefit from an attended extended
EEG given that such monitoring can be more reliable for differentiation between epileptic events and
pseudoseizures. In as much the requested out of network AEEG cannot be concluded to be the most appropriate
service that can be provided to the enrollee at this time.
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 referral have not been met. Therefore, we decided that the Plan does not
have to pre-approve a referral for an electroencephalogram (EEG) with an out-of-network in-home provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upgraded electronics, power seat elevation system, LED lights, Candy Blue shroud, and 4 pole/8mph motor package.
You asked the Plan to pre-approve upgraded electronics, power seat elevation system, LED lights, Candy Blue shroud, and 4 pole/8mph motor package. You say that you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says these items do not serve a medical purpose and cannot be covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. The items are available to the general public and would be helpful even to those who are not sick or injured. Documentation shows that you have normal range of motion and 4/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for you to be able to control the power options using their own switches which are included in the allowance of these power options. Power seat elevation systems are not covered by Medicare. The LED lights, shroud, and motor package are being requested for outside use and are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the upgraded electronics, power seat elevation system, LED lights, Candy Blue shroud, and 4 pole/8mph motor package.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9500 provided from December 28, 2019 to December 31, 2019.You asked the Plan to pay forthe home infusion therapy 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 payable.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 S9500 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9500 is not supported in the medical record. Specifically, code S9500 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9500 provided from December 28, 2019 to December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on
February 19, 2020.
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 services that are considered column II procedures to another service are not eligible for
reimbursement when billed with a column I procedure code.
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, we have confirmed that code the
services has a bundled relationship with CPT 32557 and cannot be paid as billed. This code cannot be paid as a
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on
February 19, 2020.