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

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 10, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this service was mandatory. 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 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the provider.
You asked the Plan to pre-approve the physician's services. 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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services to be provided by the provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen concentrator (CPT Code E1390) provided to the enrollee on October 30, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. 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 the DME have not been met. The prescription order indicates needs oxygen for nocturnal use, however, recent medical office encounter notes reference that member denied paroxysmal nocturnal dyspnea and there is no documentation of use of oxygen or continual need for use. Therefore, we decided that the Plan does not have to pay for oxygen concentrator (CPT Code E1390) provided to the enrollee on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from September 25, 2019 to October 1, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment per day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from September 25, 2019 to October 1, 2019.Therefore, you are responsible to pay the $290 copayment for days1-6(September 25, 2019 to September 30, 2019). $290 (copayment) x 6(inpatient days) = $1,740.You have been asked to pay the total copayment amount of $1,740 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 foran inpatient hospital stay from September 25, 2019 to October 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 30, 2019 through October 7, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid.The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 30, 2019 through October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe forearm and wrist x-rays rendered on November 17, 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 the codes were not billed with a proper diagnosis code.The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 73090 and 73110 and did not bill with a diagnosis code that indicates laterality. 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 forearmand wrist x-rays rendered on November 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 21, 2019 byan out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that this testing was medically necessary.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and 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 topay 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 October 21, 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 subsequent nursing facility care provided on March 21, 2019.You asked the Plan to pay for the subsequent nursing facility care.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 servicesat 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 subsequent nursing facility care provided on March 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered to enrollee on August 26, 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 99152 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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate the presence of an independent trained observer to assist with monitoring the patient's level of consciousness and physiological status. 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 moderate sedation services rendered to enrollee on August 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95999 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the records show 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 services rendered to the enrollee on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95999 provided on August 14, 2019.
You asked the Plan to pay for CPT code 95999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says CPT code 95999 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring. Based on this information, we decided that Medicare rules for coverage of CPT code 95999 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 95999 provided on August 14, 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 oxygenator or heat exchanger (99190) provided on December 5, 2019.You asked the Plan to pay forthe assembly and operation of a pump with 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 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on December 5, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimage guided radiation therapy (IGRT).You asked the Plan to pre-approvethe IGRT. You say that IGRT is medically necessary to allow for reproductible daily set-up, to minimize movement during daily therapy, to target the intended treatment volume noted, and to avoid the critical structuresof concern.The Plan denied your request. The Plan says the enrollee's condition responds well to radiation therapy and picture studies are not supported to guide the enrollee's type of treatment during the first phase.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 the IGRT. Our reviewer says that IGRT is not considered medically reasonable and necessary in this case. Our physician reviewer found IGRT is used with Intensity-modulated radiation therapy (IMRT). IMRT should only be used in the setting of a clinical trial, or in unique circumstances such as re irradiation, which is not seen here. Our physician reviewer found that 3D conformal is recommended and IGRT is not medically necessary.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 IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approveimage guided radiation therapy (IGRT).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 4, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that there was no emergency procedure done. You say that you shouldn't be responsible. 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 $120 copayment for emergency services in an emergency room. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that laboratory services were received during the ER visit. 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 December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 21, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the enrollee 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 subsequent nursing facility care provided on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or other tomographic modality with image postprocessing under concurrent supervision (76376) provided on October 30, 2019.You asked the Plan to pay forthe 3D rendering with interpretation. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance (MR) imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision is covered when medical necessity is established.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 3D rendering with interpretation. Our reviewer says that the service was not medically necessary. Our physician reviewer found the report of the MRI of the brain in the technique section includes a description of 3D Cube reconstruction however, there is no justification for the necessity of the 3D technique in the discussion. In other words, in order to qualify for separate reimbursement for the 3D reconstruction the exact reason why such reconstruction was necessary is required for reimbursement and no such justification is included in the report.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 3D rendering with interpretation have not been met.Therefore, we decided hat the Plan does not have to pay fora 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or other tomographic modality with image postprocessingunder concurrent supervision (76376) provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network cardiologist.You asked the Plan to pre-approvethese services. You say that you have seen this doctor for 10 years.The Plan denied your request. The Plan says the services are available from network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network cardiologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by provider from November 21, 2019 to November 27, 2019.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had already met your deductible and you should not be charged for the hospital stay. You say this is a financial hardship. 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 $275 copayment per day, days 1 to 7 at an in-network inpatient hospital. You have been asked to pay a $275 copayment for each day of the inpatient hospital stay. ($275 x 5 days = $1,375). The inpatient hospital stay falls within the "Inpatient hospital care"benefit category. The record shows you had met your deductible which means you are responsible for the copayment. 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 inpatient hospital stay provided from November 21, 2019 to November 27, 2019.