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

We decided that the Plan does not have to pay for a shingles vaccination (90471 and 90750) provided on December 16, 2019.
You asked the Plan to pay for the shingles vaccination. You say that you would like reconsideration because you were not aware that you had to go to a pharmacy to receive this immunization. The Plan denied your request. The Plan says this request is not a covered under your Medicare Part B Plan because it is a preventive vaccine. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccination. Therefore, we decided that the Plan does not have to pay for a shingles vaccination (90471 and 90750) provided on December 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on December 3, 2019.You asked the Plan to pay for the colonoscopy. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 a colonoscopy provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient mental health facility.You asked the Planto pre-approvethe admission. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no clinical information provided to suggest that the enrollee requires 24-hour-a-day, 7-day-a-week medical and nursing care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not meet the criteria for acute inpatient mental health treatment, as you were not shown to be a danger to yourself or others. You were without agitation or aggression, without perceptual disturbance including auditory or visual hallucinations.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient mental health facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe seat lift mechanism of a seat lift chair purchased on October 27, 2019.You asked the Plan to reimburse youforthe seat lift mechanism. You say that the Plan told you the seat lift mechanism was reimbursable.The Plan denied your request. The Plan says the seatlift chair was not purchased froma certified DME supplier.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare.Therefore, we decided that the Plan does not have to reimburse you forthe seat lift mechanism of aseat lift chair purchased on October 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that the Plan's denial was wrong because the sample was taken in your laboratory. 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 the ordering provider 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 services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on December 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were provided in good faith and you're asking for reconsideration of payment from the Plan.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 thePlan does not have to pay forskilled nursing services provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit, ultrasound guidance for needle placement, Sclerosant injection, and a duplex scan of extremity veins.You asked the Plan to pre-approve the physician services. You say that you provided treatment to the enrollee in 2016 and 2017.The Plan denied your request. The Plan says you are not a contracted provider. The Plan says the services can be provided in 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.You are not a network provider with the Plan as of December 31, 2019. The Plan has confirmed there are network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the office visit, ultrasound guidance for needle placement, Sclerosant injection, and a duplex scan of extremity veins.No continuity of care issue has been identified in this case.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says there is no mention of bone lesions on CT scans.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the scan. Our reviewer says that the requested scan is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was recently diagnosed with liver lesions, which appear to be consistent with cancer. The documentation notes a plan to perform chemoembolization and thermal ablation of some of the liver lesions. There is no documentation of a plan to perform a bone scan or discussion of how a bone scan would affect disease management. While it is presumed that the bone scan is an attempt to look for bony metastasis, it is unclear why this test would be preferred over an MRI, which was already planned, or a PET scan. The documentation does not currently show the requested bone scan to be medically necessary or reasonable. 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 Plan does not have to pre-approve a bone scan for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on November 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that since the member is in a nursing facility, the doctor is not responsible to get authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility 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 forskilled nursing services provided on November 1, 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 acupuncture services providedfrom October 16, 2019 to November 27, 2019.You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, orif the carecannot 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 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 pay for acupuncture services provided from October 16, 2019 to November 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on January 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood test provided to the enrollee on December 2, 2019.
You asked the Plan to pay for the blood test. The Plan denied your request. The Plan says this is not a covered
screening test.
The Plan must follow Medicare rules. Medicare rules say that that testing of patients who are asymptomatic, or
who do not have a condition that could be expected to result in a hematological abnormality, is screening and is
not a covered service.
We looked at the file and Medicare rules. The requested blood testing was performed as a screening test to an
asymptomatic patient. Based on this information, we decided that Medicare rules for coverage of the blood test
have not been met. Therefore, we decided that the Plan does not have to pay for the blood test provided to the
enrollee on December 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on October 1, 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 train of four monitoring 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 monitoring is considered integral to the primary procedure and is therefore a bundled service. 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 October 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on September 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code. IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on September 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora CT Scan of the lumbar spine (72131) and emergency department visit (99283) provided on June 9, 2019.You asked the Plan to pay for the CT Scan and emergency department visit.. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that these codes require a modifier and are not recognized by Medicare for OPPS.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 72131 and 99283 are supported in the record. Specifically, OCE edit 21 was not correctly applied in this case because there is no evidence that a procedure type T or S was also billed on this date of service. Based on this information, we decided that Medicare rules for coverage of the CT Scan and emergency department visit. have been met.Therefore, we decided that the Plan has to pay fora CT Scan of the lumbar spine (72131) and emergency department visit (99283) provided on June 9, 2019.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Electroconvulsive Therapy (90870).
You asked the Plan to pre-approve the Electroconvulsive Therapy. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the Electroconvulsive Therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does meet criteria for the use of Electroconvulsive Therapy (ECT) for the treatment of Major Depressive Disorder, as the patient is clearly documented as showing very mild symptoms. 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 Electroconvulsive Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Electroconvulsive Therapy (90870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost-stabilization inpatient care provided September 9 to September 10, 2019.You asked the Plan to pay forthe inpatient services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer to a plan facility.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 the inpatient services. Our reviewer says that coverage criteria was not met. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility after the emergency room evaluation.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 inpatient services have not been met.Therefore, we decided that the Plan does not have to pay forpost-stabilization inpatient care provided September 9 to September 10, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe root canal (D3330) for tooth # 18 provided on January 13, 2020.You asked the Plan to reimburse you forthe dental services. You say that you did not know that the dentist was out of network. You say that the facility did not advise you of this. You say that you would like toget some ofthe money reimbursed because you werenot aware. You also say that your doctor referred you there.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says you are required to receive services from a contracted dentist and at an in network site.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, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to reimburse you forthe root canal (D3330) for tooth # 18 provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower partial denture (D5212).You asked the Plan to pre-approve the dental item. The Plan denied your request. The Plan says there is a yearly allowance of $1,500 for supplemental preventive and comprehensive dental services. The Plan also says that the yearly allowance has been exhausted. 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 yearly allowance of $1,500 has been exhausted. The record shows that the Plan has approved a complete upper denture which would exhaust the remaining amount of the yearly allowance.Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5212).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a post-operative visit (99213) provided on October 29, 2019.
You asked the Plan to pay for the post-operative visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the post-operative visit is not allowed because it was included in the payment for the surgical procedure.
The Plan must follow Medicare rules. Medicare rules say that the global surgery package of procedure with a global period of 90 days includes all additional medical or surgical services required of the surgeon during the postoperative period of the surgery. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the post-operative visit have not been met. Specifically, the record indicates that this was a post-operative visit, related to the member's surgery. This is within the 90 day post-operative period and payment was included in the payment for the surgical procedure. Therefore, we decided that the Plan does not have to pay for a post-operative visit (99213) provided on October 29, 2019.