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

We decided that the Plan does not have to pay forskilled nursing services provided on December 20, 2018 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained.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 forskilled nursing services provided on December 20, 2018 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 10, 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 stating exactly what tests
are to be performed.
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 on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatrist services provided on January 14, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for psychiatrist services. You say that you were never notified that this provider was
no longer in-network. The Plan denied your request. The Plan says prior authorization was obtained. The Plan
says that there is no in-network deficiency of providers 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 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 psychiatrist services provided on January 14, 2020
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on March 9, 2020.You asked the Plan to pay forthe testing. You say that this should be paid for.The Plan denied your request. The Plan says this testing requires the use of CPT 8179.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 81479 is "unlisted molecular pathology procedure."We find that the multitude of denied codes are not supported in the case file. Specifically, the testing must be reported with CPT 81479. 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 forComprehensive Genomic Profile (CGP) testing provided to the enrollee on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the clinical documentation supports the need for LTACH care.The Plan denied your request. The Plan says the clinical information does not support that it is medically necessary to transfer the enrollee to an LTACH. The Plan says that the care needed can be provided in the current facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the current acute care hospital with pneumonia and respiratory failure. He required mechanical ventilation, tracheostomy, PEG tube feeds, chest tube, and monitoring. Weaning trials were partially successful, progressing to pressure support only and no assist control during the day. Currently, the enrollee has the chest tube removed and a significantly improved breathing status, but ongoing weaning and tube feeds are needed. Leg wound care is also needed.  The enrollee requires ongoing acute care for the time being, but does not likely require more than 25 days of acute care. Additional weaning attempts are needed, as there has already been some progress. The enrollee, however, does not require services at the LTACH that are not already available at the current acute care facility. There are no services available at the LTACH that the enrollee requires that are not already covered and available at the current facility.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 LTACHservices have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided on February 5, 2020.
You asked the Plan to pay for the echocardiography. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for an echocardiography provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing rendered on October 16, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation for code G0482. 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 definitive drug testing rendered on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on February 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 outpatient services provided on February 19, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forimaging report interpretation. You say that sending your test results to be interpreted by this provider changed the course of your treatment.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 these services could have been performed within the Plan 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 forthe medical services provided on August 14, 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 copayments for the dialysis treatments provided from
March 3, 2020 to March 7, 2020.
You asked the Plan to waive the copayments for the dialysis treatments. You say that this is too much money.
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 $30
copayment per Medicare-covered session for renal dialysis.
You have been asked to pay a $30 copayment for each of the dialysis treatments. The dialysis treatments fall
within the "Services to treat kidney disease" 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 copayments
for the dialysis treatments provided from March 3, 2020 to March 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on March 2, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable oxygen concentrator (E1392).
You asked the Plan to pre-approve portable oxygen concentrator. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. Per Medicare, oxygen is considered Durable Medical Equipment (DME), and the DME benefits require use within the home in order to be eligible for coverage and Medicare covers oxygen equipment for use within the home, but does not cover oxygen equipment for travel or specific use outside of the home and the documentation submitted does not indicate that a portable oxygen concentrator is needed, because there are no medical reasons noted that demonstrate why lightweight portable oxygen tanks will not satisfy your portable oxygen needs within the home. Therefore, we decided that the Plan does not have to pre-approve portable oxygen concentrator (E1392).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on January 23, 2020.
You asked the Plan to pay for the topical application of fluoride varnish. You say that a plan representative referred you to this provider. You also say that another Plan representative confirmed that this provider was listed as in-network with your plan, but was terminated from Medicare prior to the services you received. The Plan denied your request. The Plan says this service is not covered under your plan.
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 pay for the topical application of fluoride varnish provided on January 23, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forPT provided on January 27, 2020 and January 30, 2020.You asked the Plan to waive the copayments forPT. You say that you disagree with the charges because you were told that you would only owe a $5 copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for outpatient rehabilitation services. You received PT on January 27, 2020 and January 30, 2020. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $60. You have been asked to pay the total copayment amount of $60 for PT. PT falls within the outpatient rehabilitation services 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 copayments forPT provided on January 27, 2020 and January 30, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forcardiology services provided on January 10, 2020 to February 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forcardiology services. You say that this services were referred to you. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 hasnetwork 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 thatthe Plan does not have to pay forcardiology services provided on January 10, 2020 to February 7, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99283 and revenue code 419) provided on October 9, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not billed correctly.
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 99283 has a bundled relationship with code 94664 and cannot be paid as billed. This code cannot be paid as a separate line item. Additionally, revenue code 419 has not been billed with the required HCPCS code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99283 and revenue code 419) provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 12, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.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 2020 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 a pump with an oxygenator or heat exchanger (99190) provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 18, 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 according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.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:HCPCS G0482:Drug test(s), definitive, utilizing (1) drug identification methodsable 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 drug-specific 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; 15-21 drug class(es), including metabolite(s) if performedCPT 80307:Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA,KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the coding of the drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 18, 2019 are not supported as the available documentation does not provide any evidence of an established relationship between the member and the ordering physician.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 pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 18, 2019.