Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the power wheelchair battery purchased on August 23, 2019 from an out of network provider.You asked the Plan to reimburse you for the power wheelchair battery.You say that the in-network supplier could not get the battery for weeks and this would be several weeks after you reported the power wheelchair fail.The Plan denied your request. The Plan says that they had referred you to an in-network supplier.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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The enrollee's power wheelchair failed on August 9, 2019. It is unreasonable for the enrollee to be without a functioning power wheelchair for weeks. The in-network supplier was not able to supply the battery in a timely manner. Purchasing the battery falls under urgently needed care. Therefore, we decided that the Plan has to reimburse you for the power wheelchair battery purchased on August 23, 2019 from out of network provider.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on December 16, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that your plan doesn't require a copayment for lab work ordered by your primary care physician. You say that the test should be covered in full.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 $45 copayment for lab services at an in-network outpatient hospital. You have been asked to pay $21.67, which is less than the standard $45 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were provided by the hospital. 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 December 16, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe sleep studyprovided on October 13, 2019.You asked the Plan to waive the copayment forthe sleep study. You say that the procedure was not performed. You say that you were informed there would be no charge.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for each covered diagnostic procedure or test at a network outpatient facility.The enrollee has been asked to pay a $150 copayment for the sleep study. The sleep study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical records show that the enrollee was at the facility being prepared for the test. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe sleep study provided on October 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical careevaluation and management services(99291) providedon September 20, 2019.You asked the Plan to pay forthese 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 billed services were not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition ofcode 99291 is critical careevaluation and management of the critically ill, first 30-74 minutes.We find that CPT code 99291 is not supported in the medical record. Specifically, CPT code 99291 is a time based code. In order to bill CPT code 99291, the documentation must note that 30-74 minutes was spent providing services to the enrollee. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met.Therefore, we decided that the Plan does not have to pay forthe critical careevaluation and management services(99291) provided on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided on October 17, 2019.
You asked the Plan to pay for genetic test. You say that the enrollee's treating physician ordered this test because it was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that oncology (prostate) gene expression profile testing is not covered by Medicare for date of service October 17, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80156, 80157, 80177, 80201, 80159 and 80173 provided on July 1, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 80156, 80157, 80177, 80201, 80159 and 80173 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records for the drugs tested. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80156, 80157, 80177, 80201, 80159 and 80173 provided on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 31, 2019.You asked the Plan to pay for the services. You say that this should be reprocessed to allow the correct Medicare-allowed amounts for payment.The Plandenied your request. The Plan says there was no prior authorization, and the services were not urgent or emergent.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 anesthesia services provided to the enrollee on July 31, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that most providers cannot perform this testing. The Plan denied your request. The Plan says the denial of payment for these services 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 November 19, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe robotic surgical techniques rendered to the enrollee on November 5, 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 S2900 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.We looked at the file and Medicare rules. The provider submitted a claim for procedure code S2900 (robotic surgical techniques). This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe robotic surgical techniques rendered to the enrollee on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit (99214) and pay for the determination of a refractive state (92015) provided on November 5, 2019.
You asked the Plan to waive the copayment for the office visit and pay for the determination of a refractive state. You say that you would like reconsideration because you have not had to pay for these services in the past. The Plan denied your request. The Plan says the copayment was applied correctly and the charge for the refraction should be submitted to the provider for processing.
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 $40 copayment for specialist visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the specialist visit 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. Additionally, the determination of a refractive state has been denied correctly. This service is not included in your medical benefit, therefore this claim should be submitted to the provider for processing. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit (99214) and pay for the determination of a refractive state (92015) provided on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy.
You asked the Plan to pre-approve the endovenous ablation therapy. You say that the enrollee elevates his legs every night with very little relief in regards to the swelling. You say that the enrollee's ankles feel like they are in a vice at times. You say that the enrollee is unable to use anti-inflammatory drugs due to stomach sensitivities. You say that the records provided support the need for the requested treatment. The Plan denied your request. The Plan says the requested treatment is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy is covered when medically necessary and when coverage criteria have been met. Medicare rules also say information must be submitted that is corroborated in the enrollee's medical documentation and that confirms Medicare coverage criteria have been met. 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 endovenous ablation therapy. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of diabetes and hypertension with chest pain and exertional shortness of breath. There is no pulse examination and, on examination, the absence of edema is documented. Therefore, we are not able to attribute the enrollee's symptoms to venous insufficiency. There is no documentation in the medical record that the enrollee is having activity limiting symptoms due to venous insufficiency. Additionally there is no documentation that any concerted effort at conservative treatment was attempted. 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 endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for routine venipuncture and lab work provided on June 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for routine venipuncture and lab work. You say that these services were provide after hurricane Maria. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services are not related to the hurricane Maria event.
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 routine venipuncture and lab work provided on June 17, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Monitoring (95999) provided on August 28, 2019.
You asked the Plan to pay for the Train of Four Monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is considered a bundled procedure as the cost is included in the cost of the primary procedure.
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 record. Specifically, Train of Four is considered integral to the primary procedure and is not eligible for separate payment. 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 August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 24, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit (99214). You say that the house provider is employed by the hospital and their authorization should be included in the hospital's authorization. The Plan denied your request. The Plan says this claim was denied do to no 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 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 December 24, 2018 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lumbar spine
for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain
with radiation to the legs. The records state that various medications and exercises had been tried, although
how involved the exercise had been in the past and currently was note detailed in the provided notes. A CT
scan of the lumbar spine was performed in 2013 but the results were not provided. The low back pain is chronic
in nature with no recent flare-up or change in physical findings. The requested CT scan is not reasonable or
medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography (CT) scan of the lumbar spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on May 17, 2018.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 codes 95885 and 95999 are not supported.The Plan must followMedicare 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 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnosticprocedure.We find that CPT codes 95885 and 95999 are not supported in the medical record. Specifically, code 95885 is an add-on code, and given that the primary procedure code is not covered, the add-on code is also not covered. The file shows that train of four testing was performed, and there is a more appropriate code for these services than 95999. 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 services rendered on May 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services coded 96125, 97116, G0515 provided from September 27, 2019 to September 30, 2019.
You asked the Plan to pay for these therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are missing the appropriate modifier.
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 codes 96125, 97116, G0515 are not supported in the medical record. Specifically, CPT codes 96125-GN, 97116-GP and G0515-GN are identified as part of another procedure 96125-GN coded on the same day without an appropriate modifier therefore; we find the Medicare rule for payment of this September 27, 2019 through September 30, 2019, claim for CPT codes 96125-GN, 97116-GP and G0515-GN have not been met. Based on this information, we decided that Medicare rules for coverage of these therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services coded 96125, 97116, G0515 provided from September 27, 2019 to September 30, 2019.