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

We decided that the Plan does not have to pay for the caloric vestibular testing (92537), sinusoidal vertical axis testing (92546) and use of vertical electrodes (92547) provided on April 17, 2019.You asked the Plan to pay for the billed testing. You say that the records support the billed services.The Plan denied your request. The Plan says the denied testing is not documented in the report submitted.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The testing report does not clearly indicate that there was any caloric vestibular testing or rotational testing. Based on this information, we decided that Medicare rules for coverage of the billed testing have not been met.Therefore, we decided that the Plan does not have to pay forthe caloric vestibular testing (92537), sinusoidal vertical axis testing (92546) and use of vertical electrodes (92547) provided on April 17, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient evaluation and management (EM) services provided on July 19, 2019.You asked the Plan to pay for the EM services. You say that two providers furnished medical care on the date of service at issue and both are eligible for payment.The Plan denied your request. The Plan says that 99204 is a Column II code related to 99225 so it can only be separately paid if a modifier is reported.The Plan must follow Medicare rules. Medicare rules say that observation care codes are paid to the provider who admitted the patient to observation care. All other services are billed with the appropriate outpatient EM code.In this case, a modifier is not required as the services are from two different providers. Both providers are eligible for payment for the services provided on the same date of service.Therefore, we decided that the Plan has to pay for the outpatient evaluation and management (EM) services provided on July 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic outpatient surgery services provided by the practice on November 13, 2018.You asked the Plan to pay for the diagnostic outpatient surgery services.The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic outpatient surgery services provided on November 13, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical and occupational therapy services provided on August 20, 2019 by out of network 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 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 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 physical and occupational therapy services provided on August 20, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on January 2, 2019 by out of network provider.You asked the Plan to pay for nursing facility care. You say that the doctor is not responsible for obtaining authorization.The Plan denied your request. The Plan says this service was not authorized.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 nursing facility care (99309) provided on January 2, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for intravenous infusion (96365) and medical services provided by the practice from June 19, 2019 to June 21, 2019.

You asked the Plan to waive the copayment for intravenous infusion and medical services. You say that you were in the hospital for 3 days so the service should be covered under your inpatient hospital benefit. The Plan denied your request. The Plan says the care received was provided at an observation level of care. Therefore, the claim was billed 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 $75 copayment for same day outpatient surgery. 

You have been asked to pay $75 for intravenous infusion and medical services. Intravenous infusion falls within the same day outpatient surgery 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 intravenous infusion (96365) and medical services provided by the practice from June 19, 2019 to June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical item provided on February 3, 2019 to May 3, 2019 by out of network provider.You asked the Plan to pay for neuromuscular stimulator. You say that you were told that authorization was not required for this device, and previous months of rental were paid for.The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan. 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 item provided on February 3, 2019 to May 3, 2019 by out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department (ED) visit (99285) provided by the provider on June 2, 2019.You asked the Plan to waive the copayment for the ED visit. You say that you are not sure if you owe the copayment based on the billing you have received.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $120 copayment for emergency care. You have been asked to pay $120 for the ED visit. 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 an emergency department (ED) visit (99285) provided by the provider on June 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the Outpatient Occupational and Physical Therapy (OT/PT) services provided from May 17, 2019 to June 26, 2019.You asked the Plan to pay for the Outpatient PT/OT services. You say that the PT and OT services provided from May 17, 2019 to June 26, 2019 were medically necessary.The Plan denied your request. The Plan says the PT and OT services provided from May 17, 2019 to June 26, 2019 were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 the Outpatient PT/OT services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee is status post cerebral vascular accident October 2018 with residual right upper extremity weakness. The enrollee initially received PT and OT at an inpatient rehabilitation facility and has continued PT and OT services at the Assisted Living Facility since that time. Her level of function as of 5-9-19 PT notes and 5-15-19 OT notes was ambulating 240 feet with a rolling walker with minimal assist, transfers with minimal/standby assist, upper bodydressing independently, lower body 
dressing with minimal assist, bathing with minimal assist, and performing therapeutic exercises. The notes indicate the enrollee had plateaued with her level of function with PT and OT. Based on available records, the enrollee does not meet criteria for coverage of the PT and OT services provided from May 17, 2019 to June 26, 2019. The records do not demonstrate that the unique skills of a professional therapist were required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist during the dates at issue.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 Outpatient PT/OT services have not been met.Therefore, we decided that the Plan does not have to pay forthe Outpatient Occupational and Physical Therapy (OT/PT) services provided from May 17, 2019 to June 26, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (84550) provided on September 3, 2019.You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received additional, non-preventive laboratory services (84550) during your physical exam. The plan states the correct copayment has applied per your contract with the plan.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 $15 copayment for Outpatient diagnostic tests. We looked at the file and Medicare rules. The file shows you received a non-preventive laboratory service (84550) during your physical exam on September 3, 2019. You have been asked to pay a $4.82 copayment, which is less than the contracted $15 copayment amount for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 the laboratory services(84550)provided on September 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided January 7, 2019 to January 14, 2019.You asked the Plan to pay for IRF care. You say that medically necessary services have already been performed and you request payment.The Plan denied your request. The Plan says Medicare coverage criteria were not met for admission to an acute IRF.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 pay for 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care.  Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 pay for acute inpatient rehabilitation facility (IRF) admission and services provided January 7, 2019 to January 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve SNF services. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet skilled nursing criteria for medical issues.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services (97110, 97530 and 97116) provided on July 31, 2019.You asked the Plan to pay for the outpatient rehabilitation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says outpatient therapy services require prior authorization.Medicare rules say that plans may require enrollees to obtain authorization before receiving services. The contract with the Plan says that prior authorization is required for outpatient rehabilitation services.The Plan did not pre-approve the item/service at issue. The record indicates the Plan made multiple attempts to contact the provider and verify the required prior authorization. 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 rehabilitation services (97110, 97530 and 97116) provided on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora therapeutic, prophylactic, or diagnostic injection (96372), and a denosumab injection (J0897) provided by the practice on February 22, 2019.You asked the Plan to waive the coinsurance for injections. You say that you are requesting a reimbursement of the charges of $189.93 less the cost of the drug, under your benefits, in the amount of $8.50.You say that this is based on your continued claim of inaccurate billing practices.The Plan denied your request. The Plan says Medicare Part B prescription drugs have a 20% coinsurance. The Plan also says that covered drugs include drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician services.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 injections. This service falls within the Medicare Part B prescription drugs benefit category. The allowable amount for procedure code 96372 is $67.90 x 20% = $13.58. The allowable amount for procedure code J0897 is $881.73 x 20% = $176.35. Therefore, $13.58 + $176.35 =$189.93. 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 fora therapeutic, prophylactic, or diagnostic injection (96372), and a denosumab injection (J0897) provided by the practice on February 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy administration (96401) and a denosumab injection (J0897) provided by the physician on June 12, 2019.You asked the Plan to waive the coinsurance fora chemotherapy administration and an injection. You say that you received the injection at an infusion center and believe that the high price of the drug is suspicious and should be investigated.The Plan denied your request. The Plan says Medicare Part B chemotherapy drugs and the chemotherapy administration each has a 5% coinsurance.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 5% coinsurance for Medicare Part B prescription drugs and for the chemotherapy administration. You have been asked to pay a 5% coinsurance for the administration of chemotherapy drugs and an injection. This service falls within the Medicare Part B prescription drugs benefit category for chemotherapy drugs.CPT code for the administration is $312.91 x 5% = $15.65. CPT code J0897 is for the injection$4,813.60 x 5% = $240.68. Therefore $15.65 +$240.68 = $256.33. 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 for chemotherapy administration (96401) and a denosumab injection (J0897) provided by the practitioner on June 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal x-ray (74018) provided on August 2, 2019.You asked the Plan to pay for the x-ray. You say that the member had multiple exams on the same date of service.The Plan denied your request. The Plan says the documentation supports that services were performed by the billing provider more than once on the same date of service, but was not billed with the appropriate modifier.The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the provider rendered two abdominal x-rays to the member on the same date of service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.Therefore, we decided that the Plan does not have to pay for an abdominal x-ray (74018) provided on August 2, 2019.