Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 24, 2019.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says train of four monitoring is considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.
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 95999 is not supported in the medical record. Specifically, train of four monitoring is bundled with the primary neuromonitoring services. Train of four monitoring is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that the services were done in good faith with the expectation of payment.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.Medicare rules saythat 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 September 11, 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 the subsequent hospital care rendered on October 8, 2019 to October 10, 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 99232 is not separately covered.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99232 and 99222. Code 99232 is a column II code with a modifier indicator of 1 when billed with column I code 99222. Code 99232 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care rendered on October 8, 2019 to October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording (93229) provided on September 27, 2019.You asked the Plan to pay for the cardiovascular services. You say that you were not aware that the service was denied until after the device had been delivered to you, implemented and returned. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPTcode 93229 is not supported in the record. Specifically, G46 is a "code first" diagnosis code. The record submitted does not include medical records to indicate whether an underlying condition was known. There is not sufficient information to determine whether payment is due and the amount of payment. Based on this information, we decided that Medicare rules for coverage of the cardiovascular services have not been met. Therefore, we decided that the Plan does not have to pay for external mobile cardiovascular telemetry with electrocardiographic recording (93229) provided on September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Humalog provided on July 3, 2019.You asked the Plan to waive the coinsurance forthe Humalog. You say that this should be covered under a lower copayment.The Plan denied your request. The Plan says that this processed 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the Humalog. The Humalog falls within the Medicare Part B prescription drugs 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 coinsurance forthe Humalog provided on July 3, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95941, 95938, 95955, 95909, 95886, and 95999) provided on May 15, 2019.You asked the Plan to pay for neuromonitoring services. You say that this claim should be processed and paid.The Plan denied your request. The Plan says this claim must be submitted to the enrollee's primary insurance.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 instructed the provider to submit this claim to the enrollee's primary insurance. As the secondary insurer, the Plancannot be held responsible for neuromonitoring services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forneuromonitoring services (95941, 95938, 95955, 95909, 95886, and 95999) provided on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 6, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. You say that we processed the accepted specimen and reported our findings back to the referring provider.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained 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.Therefore, we decided that the Plan does not have to pay foroutpatient lab work provided on September 6, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network debridement services. You say that the services in dispute were medically necessary. You say that they were provided prior to obtainingauthorization in order to avoid a delay in care, which could have resulted in wound complications.The Plan denied your request. The Plan says no authorization was obtained for the non-emergency services in dispute.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 had network providers available who could have provided the debridement services at issue in this appeal. The Plan did not pre-approve the out-of-network debridement services. We found no exception that would require the Plan to pay for the out-of-network services in dispute.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 14, 2019 by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on October 23, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that this was not a specialist visit and 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 $50 copayment for each specialist visit. The record shows that you had a specialist visit on October 23, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the complete series of periapical x-rays (D0210), the 2 surgical extractions (D7210), and the topical application of fluoride varnish (D1206) provided from August 1, 2019 to August 8, 2019.
You asked the Plan to pay for the dental services. You say that you were advised the provider was in network. You say that the provider office advised that the provider was contracted through August 31, 2019 and the services would be covered. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says dental services received out of network are not covered.
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 dental services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the prophylaxis (D1110), the complete series of periapical x-rays (D0210), the 2 surgical extractions (D7210), and the topical application of fluoride varnish (D1206) provided from August 1, 2019 to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99202, CPT 72100) you received on September 23, 2019, and September 24, 2019.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these are not covered services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 99202, CPT 72100) you received on September 23, 2019, and September 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis for the enrollee.You asked the Planto pre-approve the scan. You say that this is medically necessary.The Plandenied your request. The Plansaysabdominal ultrasound would be recommended to assess kidney/liver.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is not medically reasonable and necessary. Our physician reviewer found the plan has already approved the CT of the chest. The enrollee is not obese therefore ultrasound of the abdomen and pelvis would be a reasonable first step rather than CT. EGD is planned. If either of those two tests is positive or equivocal CT would be the next procedure of choice. Incidentally, lab work particularly a BMP is not present in the chart. If lab work is abnormal concerning LFT's ultrasound would still be the first procedure of choice.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCT scan of the abdomen and pelvis for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 24, 2019.You asked the Plan to waive the copayment for an ultrasound. 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 $0 copayment for diagnostic procedures and tests provided in a physician's office and a $125 copayment for procedures at any other location.You received an ultrasound provided at an outpatient hospital facility on October 24, 2019. Therefore, you are responsible to pay the allowed amount of $102.96, which is less than the $125 copayment.  You have been asked to pay $102.96 for an ultrasound. An ultrasound falls 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 foran ultrasound provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says 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 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 to the enrollee by an out-of-network provider on September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 24, 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 services are not covered.The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests.The test at issue was not approved through the MolDx program for the date of service at issue.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 30, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that this was for your annual wellness checkup. You say that you have never had a copayment to see your primary care physician.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 $50 for lab services at an outpatient hospital. You have been asked to pay a $50 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 forlaboratory services provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plansaysthe enrollee should remain in the current setting, until a time frame where no further acute level care is required.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's 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 the enrollee'smedical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on September 30, 2019.You asked the Plan to pay forthe ambulance services. The Plandenied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 30, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on September 30, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a percutaneous implantation of neurostimulator electrode array provided on August 27, 2019.You asked the Plan to pay for the percutaneous implantation of neurostimulator electrode array. The Plan denied your request. The Plan says that thePlan 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 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 payfor a percutaneous implantation of neurostimulator electrode array provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab work. You say that your services are an extension of the initial visit. The Plan denied your request. The Plan says the referring physician is out-of-network. The Plan says that no prior authorization was obtained 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. Therefore, we decided that the Plan does not have to pay for outpatient lab work provided on September 3, 2019 by an out of network (OON) provider.