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

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided on August 5, 2019.
You asked the Plan to pay for a Tdap vaccine. You say that you would like this claim covered. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided on August 5, 2019.
Benefits for a Tdap vaccine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve a nuclear medicine study of the brain.You asked the Planto pre-approvethe study. You say that this is medically necessary.The Plandenied your request. The Plansaysthis will not provide any additional actionable information.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 study. Our reviewer says that the requested study is not considered medically reasonable and necessary in this case. Our physician reviewer found the determination of neurodegenerative parkinsonism is primarily a clinical diagnosis.DaTscan imaging has not been proven to increase the accuracy of the diagnosis of early parkinsonism.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 study have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea nuclear medicine study of the brain.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on September 9, 2019.You asked the Plan to waive the copayment forlab services. You say that you were told by the provider that you would not owe a 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 $20 copayment for laboratory tests. You have been asked to pay a $20 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 forlab services provided on September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on September 3, 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 thatthe Plan does not have to pay forthe drug testing rendered on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing tests provided on August 21, 2019.
You asked the Plan to waive the copayment for hearing tests. You say that you did not receive services and 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 $45 copayment for hearing services. The medical records show that you received hearing tests on August 21, 2019. Therefore, you are responsible to pay the allowed amount of $39.25, which is less than the $45 copayment. You have been asked to pay $39.25 for hearing tests. Hearing tests fall within the hearing 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 hearing tests provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided at a VA hospital from August 15, 2019 to August 20, 2019.
You asked the Plan to pay for the medical services. You say that you feel that you should be reimbursed for what you paid at this facility. The Plan denied your request. The Plan says Medicare does not cover services provided by the VA.
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for services provided by a Federal provider of services, such as a Veterans' Administration hospital. Therefore, we decided that the Plan does not have to pay for the medical services provided at a VA hospital from August 15, 2019 to August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set up portable x-ray, transportation of x-ray equipment, and the wrist x-rays provided on July 6, 2019 by out of network provider, Medical Diagnostic Services.You asked the Plan to pay forthe set up portable x-ray, transportation of x-ray equipment, and the wrist x-rays. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe set up portable x-ray, transportation of x-ray equipment, and thewrist x-rays provided on July 6, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 19, 2018 to September 24, 2018 by out of network provider..You asked the Plan to pay forthe medical services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.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 March 19, 2018 to September 24, 2018 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog for the enrollee.
You asked the Plan to pre-approve Novolog. You say that the enrollee needs fast-acting insulin. The Plan denied your request. The Plan says the medication does not fall under 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 Novolog for the enrollee.
Benefits for Novolog 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on September 24, 2019.
You asked the Plan to waive the copayment for the duplex scan. You say that the Evidence of Coverage does not list duplex scans. You say that you should not be charged for something not listed. 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 $150 copayment per day for ultrasounds. You have been asked to pay a $150 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The duplex scan is considered an ultrasound of the veins. 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 duplex scan provided on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan topre-approveIRF care. The Plan denied your request. The Plan says you do not need 3 hours of intensive rehab therapy a day, or monitoring by a doctor.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you are ambulating using a rolling walker with supervision, contact guard assist for sit to stand transfers, supervision for upper extremity dressing, and minimal assist for toilet and bed transfers. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physicianor nursing supervision. You may benefit and participate in additional physical and occupational therapy, but your current functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a famotidine injection (S0028) provided on October 18, 2019.
You asked the Plan to pay for a famotidine injection. You say that this should be covered. The Plan denied your request. The Plan says this code 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 S0028 is not supported in the medical record. Specifically, this code has a status indicator of "I". Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of a famotidine injection have not been met. Therefore, we decided that the Plan does not have to pay for a famotidine injection (S0028) provided on October 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on March 21, 2019.
You asked the Plan to pay for the assistant surgeon services. The Plan denied your request. The Plan says this type of provider is not payable for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided to the enrollee on March 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 30, 2019.You asked the Plan to pay forlab tests. You say that you have submitted a valid 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 include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.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 physician order or clear intent to order the specific lab testing billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions, two pontics, and two retainer crowns provided on June 10, 2019.You asked the Plan to pay for the extractions, pontics, and retainer crowns. You say that these services should be paid for by the Plan because the extractions and bridge resulted from a fall.The Plan denied your request. The Plan says your Plan does not pay for these services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe two extractions, two pontics, and two retainer crowns provided on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider from August 14, 2019, to August 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 providethe 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 forthe medical services provided by an out-of-network provider from August 14, 2019, to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 9, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.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 pump with oxygenator or heat exchanger (99190) provided on August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on February 13, 2018 by out of network provider.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 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 referring provider is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on February 13, 2018 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet rich plasma injections (0232T).
You asked the Plan to pre-approve platelet rich plasma injections. You say that this is medically necessary for your daily routine. The Plan denied your request. The Plan says that your request is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CPT 0232T is not a covered code. The requested injection is coded with CPT 0232T. Therefore, we decided that the Plan does not have to pre-approve platelet rich plasma injections (0232T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 14, 2019 by out of network provider.You asked the Plan to pay for outpatient lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider, is also out-of-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 foroutpatient lab work provided on August 14, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code Q0508 provided on June 25, 2019.You asked the Plan to pay forCPT code Q0508. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the servicesare not covered.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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide enough documentation to support their reason for denial based on Medicare payment guidelines.A complete case file, per Medicare guidelines includes all documentation used to support the Plan's denial. The Plan did not provide documentation showing CPT code Q0508 was billed and paid for on date of service, February 11, 2019.Therefore, we decided that the Plan has to pay forCPT code Q0508 provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 23, 2019 through August 27, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 23, 2019 through August 27, 2019.