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

We decided that the Plan does not have to pay forthe medical services provided on February 27, 2019 by out of network provider.You asked the Plan to pay fora specialist office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these 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 pay for care from out-of-network providersonly 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 forthe medical services provided on February 27, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) coded as E0760 provided on April 18, 2019 by an out of network provider.
You asked the Plan to pay for the DME. You say that this claim has not been paid in full for the medical equipment provided to this enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. Also, records was requested from the provider and not received.
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 durable medical equipment (DME) coded as E0760 provided on April 18, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lonhala Magnair 25mcg Refills.
You asked the Plan to pre-approve Lonhala Magnair. You say that the medication is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
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 Lonhala Magnair 25mcg Refills.
Benefits for Lonhala Magnair 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chronic care management services provided on July 31, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. You say that the services were provided to the enrollee at the request of the facility.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The requesting facility is nota network provider either. 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 forthe chronic care management services provided on July 31, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy coded 47562 provided on August 11, 2019.
You asked the Plan to pay for the laparoscopy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed without a primary 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, the CPT Code Manual definition of code 47562 is Laparoscopy, surgical; cholecystectomy. We find that CPT code 47562 is not supported in the medical record. Specifically, this code is billed with a secondary only diagnosis. A secondary diagnosis cannot be used as the primary, first listed or principal diagnosis for any procedure or service. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy coded 47562 provided on August 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialized treatment by a chiropractor services coded 98943 provided from September 16, 2019 to September 25, 2019.
You asked the Plan to pay for the specialized treatment by a chiropractor 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.
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 pay for the specialized treatment by a chiropractor services coded 98943 provided from September 16, 2019 to September 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approv ehome visits for assistance with activities of daily living (99509).You asked the Plan to pre-approve the home visits. You say that you would like reconsideration as the home health services are medically necessary. The Plan denied your request. The Plansays household assistance and custodial care are not covered benefits.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visits have not been met. Specifically, the record does not include a request or order from the physician for home skilled nursing. Additionally, there is no medical documentation showing the need for skilled services. The request on file is for custodial care. Therefore, we decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living (99509).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 16, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code G0483 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 drugspecific
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; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requisition or medical records signed by the referring
physician. In addition, the submitted order and results indicate only 15 drug classes were ordered. Based on this
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we
decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the defibrillator placement provided from September 23, 2019 through September 24, 2019.
You asked the Plan to waive the coinsurance for the defibrillator placement. You say that you stayed overnight on the cardiac floor. You say that this should be processed under your inpatient benefit. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance per visit for outpatient surgery. You have been asked to pay $5,275.56, which is less than the standard 20% coinsurance for the defibrillator placement. The defibrillator placement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that you were an outpatient. 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 for the defibrillator placement provided from September 23, 2019 through September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 14, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 14, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 27 to August 28, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient services were medically necessary.The Plan denied your request. The Plan says services could have been provided at the observation level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided medical records do not indicate any medical instability from the atrial flutter -other than heart rate, vital signs were stable, no chest pain, shortness of breath or other distress was reported. Chest x-ray showed no pulmonary edema, oxygen saturation was in the90's. Laboratory data was all essentially within normal range. Care at the observation level appears to have been appropriate for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided August 27 to August 28, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq.
You asked the Plan to pre-approve Myrbetriq. You say that this has been an effective treatment with the least amount of side effects. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Myrbetriq for.
Benefits for Myrbetriq 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-approve electrical stimulation device (E0766). You asked the Plan to pre-approvethe electrical stimulation device. You say that there is no other provider in network who can provide this service.The Plan denied your request. The Plan says the enrollee has recurrent glioblastoma multiforme and treatment requested cannot be supported for medical necessity.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  Per the LCD L34823, Tumor treatment field therapy (E0766) will be denied as not reasonable and necessary for the treatment of recurrent GBM. The enrollee was diagnosed with recurrent glioblastoma multiforme as of July 2019. Based on this information, we decided that Medicare rules for coverage of the electrical stimulation device have not been met.Therefore, we decided that the Plan does not have to pre-approveelectrical stimulation device (E0766).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019 by out of network provider.You asked the Plan to pay for radiology services. You say that you performed these services in good faith. You say that these services were supposed to be done within 24 hours which does not allow enough time to receive prior authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 for the medical services provided on July 11, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on March 29, 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 95937 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the records support 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 for the testing services rendered on March 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Otezla.You asked the Plan to pre-approveOtezla. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.The Planmust 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 Otezla. Benefits for Otezla may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on March 14, 2019.You asked the Plan to pay forthe physician services. You say that you are not aware of which insurance the enrollee has before you provide the services.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.You are not a network provider with the Plan. The rendering facility is not a network provider either. 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 forthe subsequent nursing facility care provided on March 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that you would like the claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.
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 July 2, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 17,
2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records for the billed date of
service or laboratory results for 22 or more drug classes.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided to the enrollee on July 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 24, 2019 by out of network provider.
You asked the Plan to pay for surgical services. You say that you were advised that prior authorization was not required. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for 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 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 June 24, 2019 by out of network provider.