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

We decided that the Plan does not have to pay for CPT code 77061 provided on December 13, 2019.
You asked the Plan to pay for CPT code 77061. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code 77061 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for CPT code 77061 provided on December 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation services provided September 25, 2019 to October 16, 2019.You asked the Plan to pay for inpatient rehabilitation services. You say that please review on how to process IRF inpatient rehab facility claims and reprocess this claim for payment.The Plan denied your request. The Plan says the provider has not billed the occurrence code/assessment date on claim image.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The claim is missing the occurrence code/assessment date. Based on this information, we decided that Medicare rules for coverage of inpatient rehabilitation services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation services provided September 25, 2019to October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical epidural steroid injection.You asked the Plan to pre-approve epidural steroid injection. You say that the enrollee must continue and complete physical therapy with progression to this epidural steroid injection.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service 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 epidural steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee must complete physical therapy as part of a trial of conservative therapy. Until that requirement is met, the requested service is considered medically unreasonable and unnecessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee on October 2, 2019and billed under codes 80307 and G0481.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) codes80307 and G0481 remain unsupported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician). It is noted multiple attempts were made to obtain additional information from the provider.Medicare has specific coverage criteria for definitive drug testing.  Medicare rules say that physicians and providers must produce medical records showing why the lab services provided were medically necessary. In this case, there were insufficient records provided to show the results of this testing would be used to determine a diagnosis or determine a treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes and when multiple tests are done at onetime. The physician order provided does not meet these criteria. Therefore, we decided that the Plan does not have to pay fordrug testing provided to the enrollee on October 2, 2019 and billed under codes 80307 and G0481.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to enrollee on June 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that train of four testing was performed and there is a more appropriate code for these services. 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 forthe services rendered to enrollee on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on October 21, 2019, by an out-of-network provider.You asked the Plan to pay forthe services. You say that the services are medically necessary.The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.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 thiscase 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 topay for these items/services.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on October 21, 2019, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from September 25, 2019 through October 25, 2019.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from September 25, 2019 through October 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on November 15, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you knew about the $25 charge but was not aware of the additional 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 15% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on November 15, 2019. The allowed amount is $13.11 and 20% of that is $1.97. You have been asked to pay the total coinsurance amount of $1.97 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance fora Medicare Part B drug provided on November 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.
You asked the Plan to pre-approve routine transportation. The Plan denied your request. The Plan says that neither Medicare nor the health plan covers routine transportation.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the dermatology referral. You say that you have been seeing your dermatologist for 20 years and would like to remain in their care.The Plan denied your request. The Plan says these services are available within the Plan's 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 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from December 9, 2019 to December 16, 2019.
You asked the Plan to pay for the home infusion therapy services. 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. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file, Medicare rules, and the Plan's rules. 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 for the home infusion therapy services (S9328) provided from December 9, 2019 to December 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Superion ISS).You asked the Plan to pre-approve Superion ISS procedure. You say that this procedure is medically necessary for the enrollee and Medicare supports coverage for enrollees that meet approved indications.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is experimental/investigational.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 Superion ISS procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient and conflicting evidence about the efficacy of interspinous spacers. It is still considered experimental/investigational therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion ISS procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Superion ISS).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on October 4, 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 code 99232 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99232 and 99231. Code 99232 is a column II code with a modifier indicator of 1 when billed with column I code 99231. Code 99232 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950).You asked the Plan to pre-approve the core build up. The Plan denied your request. The Plan says core build up is not listed as a covered service.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 core build up (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on November 8, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you want to know why are being charged for laboratory services taken during a physical.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 laboratory tests. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall 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 forlaboratory services provided on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve life alert bracelet.
You asked the Plan to pre-approve life alert bracelet. You say that the records should support the necessity of the services in dispute. The Plan denied your request. The Plan says this item is not a covered benefit.
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 life alert bracelet.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on January 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that train of four testing was performed and there is a more appropriate code for these services. Basedon 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 forthe services rendered on January 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cardiac rehabilitation services provided from September 4, 2019 to September 30, 2019.You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that you had already met your out-of-pocket maximum. 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 $20 copayment for each in-network Medicare-covered cardiac rehabilitative visit. You have been asked to pay a total of $230 for the cardiac rehabilitation services which is less than the standard copayment amount. The cardiac rehabilitation services fall within "Cardiac Rehabilitation Services" visit benefit category. The record shows you have met your $600 combined maximum out-of-pocket amount.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 copayments for the cardiac rehabilitation services provided from September 4, 2019 to September 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis eye emulsion.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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 Restasis eye emulsion.Benefits for self-administered drugs 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 pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 21, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone marrow biopsy provided on November 20, 2019.
You asked the Plan to waive the copayment for the bone marrow biopsy. You say that you were informed there was no charge for the procedure. 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 $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for the bone marrow biopsy. The bone marrow biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The bone marrow biopsy 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 bone marrow biopsy provided on November 20, 2019.