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

We decided that the Plan does not have to pay for transportation of a portable x-ray (R0070) provided on
January 6, 2020.
You asked the Plan to pay for the portable x-ray transportation. You say that you would like reconsideration
because this service was rendered in your mobile office. The Plan denied your request. The Plan says CPT code
R0070 has a Professional Component (PC)/Technical Component (TC) indicator of 3.
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 R0070 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code R0070 has a PC/TC indicator of 3. This indicator means that CPT code R0070 is a TC only code. The
record indicates that this member was in a Skilled Nursing Facility. The technical component must be billed by
the SNF for its Part A inpatients. Based on this information, we decided that Medicare rules for coverage of the
portable x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for
transportation of a portable x-ray (R0070) provided on January 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. There is no evidence of an ongoing SN need such as complex wound care, IV antibiotics, new enteral feedings. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your functional level does not require the ongoing skills of a professional therapist. You should be able to transition to an independent home exercise program.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on November 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an OON domiciliary or rest home visit. You say that you should not be responsible for authorization. The Plan denied your request. The Plan says this service was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 domiciliary or rest home visit provided on November 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient psychiatric hospital.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical information received shows that despite continued symptoms, there were norecent changes to the plan of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found it is not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors. You were being cooperative and compliant while not showing any acute threats to safety.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient psychiatric hospital.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on February 13, 2020.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. The Plan says that this claim should be submitted to the facility.
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. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the 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 for assembly and operation of pump with oxygenator or heat exchanger provided on February 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by provider on January 1, 2020.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you were not seen by anyone. You say you were told there would be no member responsibility.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for each Medicare-covered emergency room visit in-network and out-of-network. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for the emergency room visit.The enrollee has been asked to pay a $81.60 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows a diagnosis of constipation and you were triaged which means services were received during your emergency room visit.This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on January 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on
November 21, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says the cost of this code is included in the cost of the primary procedure.
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 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 testing. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided
do not include documentation of an unlisted neurological or neuromuscular diagnostic procedure being
performed on November 21, 2019, therefore this service cannot be verified. The operative report indicates that
Train of Four Testing was performed. Train of Four Testing is inclusive to the IONM, whether the IONM is
primarily EMG based or MEP based. There is no CPT code available for use for Train of Four Monitoring,
therefore it is inappropriate to use CPT 95999 for Train of Four Monitoring.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for train of four testing (CPT 95999) provided to the enrollee on November 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 27, 2020.You asked the Plan to waive the copayment for the ER visit. You say that you shouldn't be charged that much to remove two stiches. You say that this should have been a non-billable follow up visit.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 $90 copayment for Medicare-covered emergency room visits.You have been asked to pay $63.34, which is less than the standard$90 copayment for the ER visit. The ER visit falls within the "Emergency Care" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 ER visit provided on January 27, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit on February 5 to February 6, 2020.
You asked the Plan to waive the copayment for the Emergency Room Visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was a applied.
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 $90 copayment for Emergency Care. You have been asked to pay a $72.58 copayment for the Emergency Room Visit. The Medicare allowable amount is less than the $90 stipulated in the plan contract. The Emergency Room Visit falls within the Emergency 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 waive the copayment for an Emergency Room Visit on February 5 to February 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you fell on a concrete sidewalk and injured your head and legs. Local paramedics were called and they treated you and provided you with aid. You say that you were subsequently released by the paramedics and you were transported to the hospital by your wife and a friend. You asked the Plan to process the claim and reimburse you for the cost of the services except for any copay you may be responsible for.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 December 14, 2018. 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 forthe ambulance services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient office visit for the evaluation and management of an established patient(99212) provided January 27, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you feel that you should not owe the copayment because it was just a few days after the doctor had already checked your eye on 01/22/2020 and she was rechecking it to make sure it was healing.The Plan denied your request. The Plan says this claim was processed correctly based on the plan benefits.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 clearlysays that you must pay $35 copay for each Medicare covered eye exam to diagnose and treat diseases and conditions of the eye. You have been asked to pay $35 for the office visit. The office visit falls within the Vision care benefit category. This meansthat 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 foroutpatient office visit for the evaluation and management of an established patient (99212) provided January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approve IRF care. You say that the enrollee is ready to start rehab and physical therapy. The Plan denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There does not appear to be a medical need for the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskin tag removal.You asked the Plan to pre-approveskin tag removal. 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 skin tag removal. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation in the office visit note of March 10, 2020, of any irritation, pain, or bleeding related to the skin tags.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin tag removal have not been met.Therefore, we decided that the Plan does not have to pre-approveskin tag removal.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.
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 office visit provided on July 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physician services provided on December 19, 2019.
You asked the Plan to waive the deductible for physician services. You say that you disagree agree with the out-of-network 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. Your contract with the Plan says that there is a $1,500 deductible for out-of-network physician/practitioner services, including doctor's office visits. You received physician services from an out-of-network provider on December 19, 2019. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had only paid $133.19 toward the $1,500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $107.34. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time physician services was received on December 19, 2019. Therefore, we decided that the Plan does not have to waive the deductible for physician services provided on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on January 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
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. Payment for all fees related to these services would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on January 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered 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 forthe laboratory services provided on January 22, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 98943) provided on January 22, 2020, and January 27, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered from a chiropractor.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 chiropractic services (CPT 98943) provided on January 22, 2020, and January 27, 2020.