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

We decided that the Plan does not have to pay forthe services rendered on February 14, 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 codes 95909, 95885, and 95999 are 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 95909 is nerve conduction studies; 5-6 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT codes 95909, 95885, and 95999 are not supported in the medical record. Specifically, the intraoperative monitoring does not support that 5-6 nerve conduction studies were performed to support code 95909. Code 95885 is an add-on code for 95909 and given that the primary code is not supported, the add-on code of 95885 is also not supported. The documentation indicates that train of four testing was performed and there is a more specific code for these services than 95999. 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 on February 14, 2019
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approvesleep monitoring of a patient (6 years or older) in a sleep lab with continuedpressured respiratory assistance by mask or breathing tube (95811) to be provided.You asked the Plan to pre-approvesleep monitoring. You say that you received evidence that the enrollee's download from November 6, 2019 does indeed show 4 hours or more use 70% of nights. He has persisted symptoms on continuous positive airway pressure (CPAP) including excessive daytime sleepiness characterized by an Epworth Sleepiness Scale of 13 (normal 0-10).The Plan denied yourrequest. The Plan says that there must be a face to face evaluation and clinical information that indicates that a home sleep study cannot be done. There is no documentation that suggests a home sleep study can't be done.The Plan follows Medicare rules. Medicare rules say that effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act. 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 sleep monitoring. Our reviewer says that the service was medically necessary. Our physician reviewer found an attended polysomnography (PSG) for the purposes of positive airway pressure therapy (PAP) titration is considered reasonable and necessary for this patient. PAP titration studies cannot be done at home, and must be done attended, in a sleep lab. This patient has persistent symptoms on auto-titrating continuous positive airway pressure (CPAP) and has persistent sleep disordered breathing when using the CPAP (Apnea-HypopneaIndex [AHI] 10.6). That is an accepted indication for a PAP titration study, to find settings that are effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sleep monitoring have been met.Therefore, we decided that the Plan has to pre-approve sleep monitoring of a patient (6 years or older) in a sleep lab with continued pressured respiratory assistance by mask or breathing tube (95811) to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 12, 2019 to September 10, 2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient visits (99213 and 99204) and vascular ultrasound (93970). You say that you would like reconsideration so you are able to take care of your condition and receive necessary medical treatment. The Plan denied your request. The Plan says you did not require prior authorization and these services are available within your health 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 for the medical services provided on March 12, 2019 to September 10, 2019 by an out of network (OON) provider.
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-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services 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 the medical services provided on June 3, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 3, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), and a urinalysis with a scope (81001) provided on November 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for a hospital outpatient clinic visit, and a urinalysis with a scope. You say that the service provided was clinically appropriate and medically necessary as stated in the supporting documentation.The Plan denied your request. The Plan says the doctor and the rendering facility Hospital are non-participating providers. The plan did not authorize any services for Hospital or the Out of Network. There is no referring provider on file. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature. Services rendered by non-participating providers, require prior authorization as outlined in the enrollee's EOC.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 a hospital outpatient clinic visit (G0463), and a urinalysis with a scope (81001) provided on November 6, 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 copayment for a specialist visit with provider on August 8, 2019.You asked the Plan to waive the copayment for a specialist visit. You say that you should owe a primary care physician 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit with provider on August 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care (99308) provided on April 10, 2019 by an out of network(OON) provider.You asked the Plan to pay forsubsequent nursing facility care. You say that you are appealing the denied claim for payment.The Plan denied your request. The Plan says "the doctor" is not an in-networkprovider. There is no authorization on fileand theservice was not plan directed.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 forsubsequent nursing facility care (99308) provided on April 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) care provided on August 13, 2019 by an out of network (OON) provider.You asked the Plan to pay forSNF care. You say that you rendered services for a patient and it is the responsibility of the surgeon and/or the facility to obtain authorization. You should not be penalized for the facility's failure to obtain authorization. This was an emergency admission and not a pre-scheduled admission. Medical records support the medical necessity.The Plan denied your request. The Plan says the services or items were provided by an out-of-network provider, which requires pre-approval by your primary care physician (PCP) or the Plan. Our records indicate this pre-approval 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 facility (SNF) care provided on August 13, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 12, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 nurse practitioner services provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography provided on July 23, 2019 by an OON provider.
You asked the Plan to pay for the echocardiography. The Plan denied your request. The Plan says this service was rendered by a non-participating provider. The Plan also says the services were not authorized by 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 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 transthoracic echocardiography provided on July 23, 2019 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B injectable drug or the infusion
service provided on June 14, 2019.
You asked the Plan to waive the cost share for the Part B injectable drug and an infusion service. You say that
these services are necessary in order to avoid the rejection of your transplant. You say you cannot afford these
charges. 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 20%
coinsurance for all other in-network drugs covered under Medicare Part B and a $40 copayment for in-network
specialist services (including surgery second opinion and telehealth or urgently needed services).
You have been asked to pay a total of $417.70 for the Part B injectable drug and an infusion service. The Part
B injectable drug falls within the "Medicare Part B prescription drugs" benefit category. The infusion service
falls within "Physician/Practitioner services, including doctor's office visits" benefit category. See chart below.
Date of Service Service Allowed Amount Coinsurance/Copayment Member
Liability
June 14, 2019 Part B drug
injection
$1,888.50 20% $377.70
June 14, 2019 Infusion service $181.08 $40.00 $40.00
Total $417.70
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 cost share for the Part B injectable drug or the infusion service provided by
on June 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on August 6, 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. 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 drug testing rendered to the enrollee on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on February 20, 2019 to November 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for nursing facility care. You say that these services should be covered.The Plan denied your request. The Plan says these services were 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 nursing facility care (99308) provided on February 20, 2019 to November 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 copayment forthe urgent care visit provided on October 22, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that they did not diagnose the condition correctly. You say that you shouldn't have to pay the copayment.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 $65 copayment per visit for covered services to a medical facility or urgent care center.You have been asked to pay $61.55, which is less than the standard $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 copayment forthe urgent care visit provided on October 22, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the hip (73502) provided by Out of Network Provider on April 8, 2019.You asked the Plan to pay for the X-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim as submitted is a duplicate of a previous claim.The Plan must follow Medicare rules. Medicare rules say that providers must reportservices correctly. Providers must report services with the appropriate CPT code.We find that CPT code 73502 is not supported in the medical record. Specifically, there is no modifier to indicate a repeat service. Without this modifier, the claim is a duplicate of claim 19109E0BBT00 which was already processed. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met.Therefore, we decided that the Plan does not have to pay foran X-ray of the hip (73502) provided by Out of Network Provider on April 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Test strips (A4253).You asked the Plan to pre-approvethe One Touch Ultra Test Strips. You say that the test strips are medically necessary.The Plan denied your request. The Plan says the test strips requested here are not a brand the plan covers.The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred. We looked at the file and Medicare rules. The test strips requested are not a plan-preferred brand. The record shows the provider has informed the plan that there is no reason the enrollee cannot use the preferred brand. Based on this information, we decided that Medicare rules for coverage of the One Touch Ultra Test Strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOne Touch Ultra Test strips (A4253).