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

We decided that the Plan does not have to pay forthe surgical services rendered to "the beneficiary" by "the doctor" on May 10, 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 codes 14301 and 15002 are 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 of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 15002 is preparation of graft site at trunk, arms, or legs (first 100 sq cm or 1% body area infants and children).We find that CPT codes 14301 and 15002 are not supported in the medical record. Specifically, the recordsdo not document the exact dimensions of the primary and secondary defects and all incisions to support code 14301 and the operative report does not contain documentation of the first 100 square centimeters of skin grafts to support code 15002. 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 surgical services rendered to "the beneficiary" by "the doctor" on May 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 2, 2019 to October 21, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate theDelivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 2, 2019 to October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided onJuly 18, 2019 by the out of network provider.You asked the Plan to pay forthe practitioner services. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says the enrollee self-directed for the services. The Plan also says 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 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 office visit provided on July 18, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by the Provider from May 29, 2019 to August 17, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by the Provider from May 29, 2019 to August 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided to the enrollee from August 29, 2019 to September 5, 2019.
You asked the Plan to pay for the home infusion 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 not payable.
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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided to the enrollee from August 29, 2019 to September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 and 80307 provided to the enrollee on April 17, 2019.
You asked the Plan to pay for the drug testing. 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 code G0480 and 80307 is not supported in the medical record. Specifically, form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0480 and 80307 provided to the enrollee on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump coded 99190 provided to the enrollee on August 20, 2019.You asked the Plan to pay forthe assembly and operation of pump. 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 separately payable.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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour.We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided to the enrollee while the enrollee was inpatient in the hospital. The services are included in the facility DRG payment. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump have not been met. Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump coded 99190 provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received on August 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943).
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 20, 2019 by an out of network provider..You asked the Plan to pay forspecialist services. You say that you would like this claim to be reprocessed and approved for payment. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring doctor 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 forthe medical services provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services coded 99153 provided to "the beneficiary" on June 4, 2019.You asked the Plan to pay forthe moderate sedation 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.In this case, the CPT Code Manual definition of code 99153 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).We find that CPT code 99153 is not supported in the medical record. Specifically, the documentation submitted and claim form indicate that this procedure was performed in a facility place of service of 22. Payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service; therefore, the billed service cannot be supported. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay forthe moderate sedation services coded 99153 provided to "the beneficiary"  on June 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided to "the beneficiary" from July 20, 2019 to July 27, 2019.You asked the Plan to pay forthe home infusion 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 not a covered benefit.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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not supported in the medical record. Specifically, this code is not valid for Medicare purposes. Medicare uses another code for reporting of and payments of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services coded S9328 provided to "the beneficiary" from July 20, 2019 to July 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the resin based composite (D2392) provided on July 29, 2019. You asked the Plan to pay the in network rate for the dental services. You say that you were advised by a Plan representative that the provider was in network. You say that you paid $362 for the provisional crown. You say that since the provider is out of network, you do not want to go back. You also say that this claim should be paid at the in network rate.The Plan denied your request. The Plan says that the provider is not contracted with the Plan. The Plan also says that the correct cost sharing amount for out of network services was applied to the dental services. 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 and the services you received are covered services, there is a 50% coinsurance applied when you receive the services out of network. The record shows that the Plan representative did give names of in network dentists, but they did not include the provider. Additionally, the record shows the provider also advised that they were out of network with the Plan.Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), the periapical x-ray (D0220), and the resin based composite (D2392) provided on July 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 8, 2019 through June 13, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 8, 2019 through June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient care from 11:15AM on March 30, 2019 through March 31, 2019.You asked the Plan to pay forinpatient care. You say that this care was medically necessary.ThePlan denied your request. The Plan says as of 11:15 AM on March 30, 2019, the enrollee was stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found based on the records, provided the patient appeared to be stable for transfer as of 11:15AM on March 30, 2019.The patient wasseen and managed by trauma surgery. No surgical intervention was deemed necessary. No other acute injury or medical issues were noted in the provided medical records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient care from 11:15AM on March 30, 2019 through March 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services provided on June 3, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99152 (1 Unit) remains 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 of code 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15minutes of intra service time, patient age 5 years or older."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 services at issue in this case were not coded correctly. Our coding reviewer found the case file does not appear to contain a procedure report or medical records. The code cannot be verified.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 moderate sedation services on June 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient post-stabilization care provided.
You asked the Plan to pay for inpatient post-stabilization care. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was stable for transfer to an in-network hospital after 10:00am.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient post-stabilization care. Our reviewer says that these inpatient hospital services do not meet the Medicare criteria for coverage. Our physician reviewer found the records show that the enrollee was not stable for transfer from admission through 10:00am. However, the enrollee was stable for transfer after 10:00am. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient post-stabilization care provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forRadiology Services (G0279, 19000, 77066, 76942) provided on April 30, 2019.You asked the Plan to pay forthe radiology services. You say that the services were medically necessary and properly billed.The Plandenied your request. The Plan says services must first be processed 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 attempted to obtain an Explanation of Benefits from 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 forRadiology Services (G0279, 19000, 77066,76942) provided on April 30, 2019.