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

We decided that the Plan does not have to pay for hyperthermia treatment (77605 and 77280) provided on December 11, 2018 by out of network provider. You asked the Plan to pay for hyperthermia treatment. You say that these services should be considered authorized because of the letter you received from the enrollee's PCP.The Plan denied your request. The Plan says there was no valid referral or authorization for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The letter you received about medical clearance does not constitute a valid referral.Therefore, we decided that the Plan does not have to pay for hyperthermia treatment (77605 and 77280) provided on December 11, 2018 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99497, CPT 99498) provided to the enrollee on May 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
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 99497 is "Advance care planning including the
explanation and discussion of advance directives such as standard forms (with completion of such forms, when
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the
patient, family member(s), and/or surrogate". The CPT Code Manual definition of code 99498 is "Advance
care planning including the explanation and discussion of advance directives such as standard forms (with
completion of such forms, when performed), by the physician or other qualified health care professional; each
additional 30 minutes (List separately in addition to code for primary procedure)".
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use
of CPT codes 99497 and 99498 is not supported by the records provided. Our coding reviewer found that the
record does not contain the amount of time spent providing advance care planning services. It cannot be
verified that the time requirement for reporting these codes has been met.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (CPT 99497, CPT 99498) provided to the enrollee on May 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to "the beneficiary"  on July 9, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules.The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided to"the beneficiary" on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe adjunctive prediagnostic test, or pay more for the periodic oral evaluation, bitewings, and prophylaxis provided on August 21, 2019.You asked the Plan to pay forthe adjunctive prediagnostic test, periodic oral evaluation, bitewings, and prophylaxis. The Plan denied your request. The Plan says adjunctive prediagnostic test is not a covered benefit. The Plan also says that this provider is out-of-network with your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the adjunctive prediagnostic test is not among those covered under this benefit. Your contract also clearly shows that the Plan is only obligated to pay  50% of the allowed amount for periodic oral evaluations, bitewings, and prophylaxis when the services are received out-of-network. The Record shows that you saw an out-of-network provider, so the Plan does not have to pay the in-network benefit rates for these services.
ServiceBilled AmountAllowed Amount50% coinsuranceDifference of Billed & Allowed AmountMember LiabilityOral Evaluation$51$20$10$31$41Bitewings$66$28$14$38$52Prophylaxis$81$43$21.50$38$59.50TOTAL:$152.50Therefore, we decided that the Plan does not have to pay forthe adjunctive prediagnostic test, or pay more for the periodic oral evaluation, bitewings, and prophylaxis provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered to the enrollee by the 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered to the enrollee by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) and critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this 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. We find that CPT code 99239 and 99291 is not supported in the medical record. Current Procedural Terminology (CPT) code 99291 (2 Units) remains not supported. The documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed dates of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Current Procedural Terminology (CPT) code 99239 (1 Unit) remains not supported. The submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Therefore, the billed
service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) and critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for microscopic genetic examination using computer-assisted technology provided on (88374) July 22, 2019 by out of network provider.You asked the Plan to pay for microscopic genetic examination. You say that you have enclosed reports supporting the services rendered and want the claim reprocessed for additional payment.The Plan denied your request. The Plan says the services are not authorized because the provider is a non-network provider who does not work with the member's health plan, and the member was referred by a doctor, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 providerwith 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 microscopic genetic examination using computer-assisted technology provided on (88374) July 22, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent nursing facility care (99308) provided on August 22, 2019 by an out of network provider. You asked the Plan to pay fornursing facility care. You say that you want the claim processed as in network because the provider,"nurse practitioner", is the only wound specialist and works for the nursing home. You say that the patient is currently residing at the nursing home and had no choice of which provider should come see him.The Plan denied your request. The Plan says the member has no out-of-network benefits. The services are not authorized because "nurse practitioner", is a non-network provider who does not work with the member's health plan and the member was referred by her non-participating nursing facility. The member'sprimary care physician (PCP) did not refer for services.  The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 August 22, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered to the enrollee.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the myocardial perfusion, the stress test, the technetium dose and the regadenoson injection provided on December 12, 2018.You asked the Plan to waive the cost share for the myocardial perfusion, the stress test, the technetium dose and the regadenoson injection. You say that you were not informed of a copayment before the scan. You say that the cost should be waived.The Plan denied your request. The Plan says the cost share 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 10% of the cost for Medicare-covered diagnostic radiology services, a $25 copayment for Medicare-covered cardiac stress tests, 20% of the cost for Medicare-covered medical supplies and 10% of the cost for Part B-covered Drugs covered under Medicare Part B.You have been asked to pay a total of $244.62 for the myocardial perfusion, the stress test, the technetium dose and the regadenoson injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider.
You asked the Plan to pay for an EKG. You say that you were sent to get an EKG because of the medication you are taking. You say that you do not like the UBH mental health providers so you pay out of pocket for those services. The Plan denied your request. The Plan says there was no prior authorization obtained for the service in question. 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 for the medical services provided by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided by "the provider" on June 1, 2019.You asked the Plan to pay forthe ambulanceservices. You say that the services were medically necessary.The Plan denied your request. The Plan says the run report was requested but not received.Medicare pays for ambulance services only when they are medically reasonable and necessary. ThePlan follows the same rules. We looked at this the file and Medicare rules. There are no records to support medical necessity. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forservices provided by "the provider" on June 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the 50 mL of low osmolar contrast material (Q9967) and lidocaine injection (J2001) billed for services provided on June 3, 2019.You asked the Plan to pay for the contrast material and lidocaine injection. You say that this is billed correctly and should be paid in full.The Plan denied your request. The Plan says although there is documentation of contrast material being used, the type used and the amount is not documented. As such, 50 units of Q9967 is not supported. In addition, payment for a lidocaine injection is included in payment for code 27369. There is no evidence the injection was separate from the procedure so the use of the -59 modifier is not appropriate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Without documentation of the type or amount of contrast material used, the billed amount of Q9967 is not supported. In addition, lidocaine is only separately payable when billed with code 27369when it is not used in conjunction with that procedure. In this case, there is no evidence that the lidocaine injection was a separate and distinct service. Based on this information, we decided that Medicare rules for coverage of the contrast material and lidocaine injection have not been met.Therefore, we decided that the Plan does not have to pay forthe 50 mL of low osmolar contrast material (Q9967) and lidocaine injection (J2001) billed for services provided on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by out of network provider.You asked the Plan to pay for office visit. You say that you do not agree with the denial and are appealing with records.The Plan denied your request. The Plan says the denial of payment for this service 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 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 July 9, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology services (72157) provided on July 5, 2019.You asked the Plan to pay for the radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim must first be paid by the primary insurer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made multiple attempts to obtain an explanation of benefits issued by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the radiology services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for Radiology services (72157) provided on July 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by an out of network provider.
You asked the Plan to pay for office services. You say that you would like this appeal to be reprocessed and approved for payment. The Plan denied your request. The Plan says there was not prior authorization obtained for the service in question.
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 July 24, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 21, 2019 by an out of network provider.
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for the service in question.
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 May 21, 2019 by the out of network provider.