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

We decided that the Plan does not have to pay for chiropractic services provided on December 18, 2019.You asked the Plan to pay for the chiropractic 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 chiropractic services. 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 chiropractic services provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician services provided on January 7, 2020.You asked the Plan to waive the deductible for the physician services. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received physician services on the date of service at issue in this appeal. The Plan says that the correct amount has been applied towards your deductible per your contract with the Plan.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 $198 deductible for Physician/Practitioner services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Physician/Practitioner services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $198 deductible for Physician/Practitioner services. This cost sharing is a contractual obligation that had not been met at the time the physician services were received on January 7, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe physician services provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99215). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained and there are in-network providers available within a reasonable distance to the member that could perform the requested service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for iron sucrose injections (J1756, 96375) and to waive the coinsurance for the chemotherapy services (J9035, 96413) provided from December 26, 2019 to January 16, 2020.You asked the Plan to hold you harmless for these services. You say that the Plan has not paid their share of these services.The Plan denied your request. The Plan says that the claim was processed correctly,and no additional payment is due.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The rules also say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, there is no information(such as an Explanation of Benefits)to show how Original Medicare processed these claims. We cannot verify if the amount being paid by the Plan is correct based on your contract and based on what Original Medicare already paid. The Plan contract also says that there is no coinsurance for administration of drugs in a specialist's office.The drugs at issue were administered in a specialist's office.This means that you should have no cost-share responsibility for these services(J9035, 96413).Therefore, we decided that the Plan must hold you harmless for iron sucrose injections (J1756, 96375) and waive the coinsurance for the chemotherapy services (J9035, 96413) provided from December 26, 2019 to January 16, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95937) provided on September 25, 2019.You asked the Plan to pay for train of four testing. You say that this is a billable code.The Plan denied your request. The Plan says this code is not appropriate for the provided service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the medical record. Specifically, the use of this code to report train of four testing is not supported. According to CPT coding rules, train of four testing is not aseparately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95937) provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services rendered on October 22, 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 code G0500 is not supported.The Plan must follow Medicare rules. Medicare rulessay 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 G0500 is moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate).We find that CPT code G0500 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in 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 forthe moderate sedation services rendered on October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 23, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea multi-level lumbar fusion.You asked the Plan to pre-approvea multi-level lumbar fusion. You say that the requested multi-level lumbar fusion is medically necessary.The Plan denied your request. The Plan says the requested multi-level lumbar fusion does not meet criteria. 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 a multi-level lumbar fusion. Our reviewer says that the requested multi-level lumbar fusion does not meet criteria. Our physician reviewer found this enrollee presents with persistent and worsening lowback pain with lower extremity radiculopathy. Functional limitations are noted in activities of daily living and ambulation. Clinical exam findings have documented motor deficits and reflex changes consistent with imaging evidence of severe stenosis at the L2/3, L4/5 and L5/S1 levels. There is radiographic evidence of minimal spondylolisthesis at L4/5 and L5/S1 with no spinal segmental instability on flexion and extension x-rays. He is status post prior multilevel laminectomies, without a clear surgical history. He has reportedly failed 6 months of reasonable and/or comprehensive conservative treatment. Under consideration is a request for multilevel lumbar fusion. This enrollee has multiple indications to support spinal surgery, including significant lumbar spinal stenosis and motor weakness. However, the medical necessity of surgery cannot be fully established as a specific surgical treatment plan including the specific spinal levels is not available in the submitted medical records. Therefore, the enrollee does not have a covered indication for multilevel lumbar fusion 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 a multi-level lumbar fusion have not been met.Therefore, we decided that the Plan does not have to pre-approvea multi-level lumbar fusion.
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 an oxygenator or heat exchanger (99190) provided on February 11, 2020. 
 
You asked the Plan to pay for the 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 for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.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 physician services provided on May 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 enrollee does not require services (decannulation, PT) at the proposed LTACH that are not already available at the current acute care facility. Based on the continued improvement, it is unlikely he will require more than 25 days of acute care services to justify LTACH transfer. There are no services available at the LTACH that the enrollee requires that are not available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary 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-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visit (99213) provided on November 22, 2019 through December20, 2019.You asked the Plan to waive the copayment for the office visits. You say that you would like reconsideration because you were told this provider was in-network.The Plan denied your request. The Plan says you are responsible for a $45.00 copayment for services received from an out-of-network primary care provider.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 two $45 copayments for out-of-network primary care services. You have been asked to pay two $45 copayments for the office visits. The office visits fall within the out-of-network primary care 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 for office visit (99213) provided on November 22, 2019 through December 20, 2019.Your complaint about being given incorrect information about the network status of this provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on November 1, 2019. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says nonemergent, 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 chiropractic services. 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 chiropractic services provided on November 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Midodrine tablets.You asked the Plan to pre-approve the Midodrine. You say that the enrollee has been stable on the current medication and wish for no changes to be made.The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve the Midodrine tablets.Benefits for Midodrine may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 14, 2020.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 claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable


 We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98942) and the pain assessment (G8730) rendered by the out of network provider on December 11, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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. 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 the chiropractic manipulative treatment (98942) and the pain assessment (G8730) rendered by the out of network provider on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the application of a multi-layer compression system and debridement provided on January 15, 2020 and January 29, 2020. 
 
You asked the Plan to waive the copayments for the application of a multi-layer compression system and debridement. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received the application of a multi-layer compression system on January 15, 2020. This is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $203.75, which is less than the $250 copayment.  
 
You received debridement on January 29, 2020. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment.  
 
The total amount you owe is: $453.75.   
 
You have been asked to pay the total copayment amount of $453.75 for the application of a multi-layer compression system and debridement. The application of a multi-layer compression system and debridement fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 application of a multilayer compression system and debridement provided on January 15, 2020 and January 29, 2020.