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

We decided that the Plan does not have to pay for the outpatient lab services you received on June 28, 2018.
You asked the Plan to pay for the lab services. You say that you are covered for pathology. The Plan denied your request. The Plan says the claim was not submitted within the allotted timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the lab services was not filed until August 28, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient lab services you received on June 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network
provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the provider is out-of-network, and there are in-network options available.
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 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. 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
a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Unna boot services rendered on June 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed in excess of the MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 29580 is 1. You billed 2 units of this code, exceeding the MUE. 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 for the Unna boot services on June 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous positive airway pressure device (E0601)
provided on February 28, 2019.
You asked the Plan to pay for the continuous positive airway pressure device. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure code
E0601 is billed with RR modifier and billed without a GA, GZ or KX modifier so procedure code E0601 is
rejected as missing information.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code E0601 is not supported in the record. Specifically, the claim submitted does not include
the required GA, GZ or KX modifier. Based on this information, we decided that Medicare rules for coverage
of the continuous positive airway pressure device have not been met. Therefore, we decided that the Plan does
not have to pay for a continuous positive airway pressure device (E0601) provided on February 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require frequent intervention by a rehab physician, and would not be able to do 3 hours of therapy a day.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is at supervision for toileting, contact guard assist for ambulation using a rolling walker, and contact guard assist for transfers. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The recent documentation reveals the enrollee is clinically improving. He may benefit and participate in additional physical and occupational therapy, but does not require this or appear to be able to tolerate this therapy on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health visits provided to June 6, 2019 to July 18, 2019 by an out of network provider.
You asked the Plan to pay for home health visits. You say that these services should be covered. The Plan denied your request. The Plan says these services were 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 the home health visits provided to June 6, 2019 to July 18, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring
(95941) provided on September 9, 2019.
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring. You say that these
services meet the criteria for coverage. The Plan denied your request. The Plan says this code is not valid for
Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Codes
with a status indicator of "I" are not valid for Medicare purposes.
We find that CPT code 95941 is not supported in the medical record. Specifically, this code has a status
indicator of "I" and is not valid for Medicare purposes. Based on this information, we decided that Medicare
rules for coverage of continuous intraoperative neurophysiology monitoring have not been met. Therefore, we
decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring (95941)
provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 21, 2017.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was filed
after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until July 15, 2019. This means that more than one
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan
does not have to pay for the services provided on November 21, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the somatosensory testing rendered on March 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 95938 with POS code 15 for a mobile unit. The file shows that the enrollee was under inpatient status for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the somatosensory testing rendered on March 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81173, 81201, 81121, 81120) provided on June 12, 2019 by an out of network provider.
You asked the Plan to pay for genetic testing. You say that an in-network provider, ordered a blood biopsy in assisting treatment options for his patient and signed a statement of medical necessity. The diagnosis from the practice enabled the doctor to determine the optimal treatment pathway for his patient. The Plan denied your request. The Plan says the enrollee self-referred to the doctor. The serum drawn was sent to an out-of-network provider. The service was not authorized in compliance with the Plan's procedures, was not requested by Plan provider, and did not meet emergent care criteria.
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 genetic testing (81173, 81201, 81121, 81120) provided on June 12, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on August 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99152 is 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 by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of the presence of an independent trained observer to assist in monitoring the enrollee's consciousness and physiological status. 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 for the moderate sedation services rendered on August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 18, 2019 by the 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 a non-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 laboratory services provided on June 18, 2019
by the out of network provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the emergency ambulance services provided  June 17, 2019.
You asked the Plan to pay for the ambulance services. You say that the claim has already been billed to the
primary payer and was adjudicated and the primary EOB is attached. The Plan denied your request. The Plan
says that the no fault carrier payment exceeded the plan's allowable.
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 auto carrier, covered 80% of the billed charges as the primary payer. The actual charge of $730.75 minus
the primary payment of $584.60 = $146.15. Therefore, the plan, has to pay the secondary payment in the
amount of $146.15. Therefore, we decided that the Plan has to pay for the emergency ambulance services
provided June 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast tomosynthesis (77061) provided on June 26, 2019.
You asked the Plan to pay for the breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 77061 has a status code of I which is not valid for Medicare purposes.
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 77061 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, 77061 has a status code of I. This means that 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (77061) provided on June 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the plan does not have to pre-approve Metformin 500mg ER Tablets.
You asked the plan to pre-approve Metformin. You say that the drug is medically necessary for treatment of
neuropathy. The plan denied your request. The plan says Metformin must be submitted to the Part D Pharmacy
benefit. Self-administered drugs are not eligible for coverage under the Part B medical benefit.
The plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the plan does not have to pre-approve Metformin 500mg ER
Tablets.
Benefits for Metformin may be available under Medicare Part D. Contact the health plan that administers Part
D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the PAP supplies provided on May 17, 2019.
You asked the Plan to pay for the PAP supplies (A7030, A7037, A7038, A7039). You say that the Plan should
pay this claim. The Plan denied your request. The Plan says that you billed with KX modifiers and there is no
info of ICES history for this code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided any single citation which indicates that the KX
modifier is not appropriate. There is not sufficient evidence to support the denial of payment in this case.
Therefore, we decided that the Plan has to pay for the PAP supplies provided on May 17, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
September 18, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says a Treatment Authorization Code is necessary to
be indicated on the claim for payment purposes.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim
that was submitted does not include the required Treatment Authorization Code. Therefore, we decided that the
Plan does not have to pay for the home health services provided to the enrollee from September 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee on February 15, 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 this claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims require a treatment authorization code. The case file did not contain a valid treatment authorization code. 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 home health services provided to the enrollee on February 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services (17000, 17003, 17111, 17273, and 99214) provided on July 12, 2019 by out of network provider
You asked the Plan to pay for dermatology services. You say that these services should be covered. The Plan denied your request. The Plan says these services were 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 the dermatology services (17000, 17003, 17111, 17273, and 99214) provided on July 12, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing provided on
February 4, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed
services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that UDT orders should be individualized based on
clinical history and risk assessment, and must be documented in the medical record.
We looked at the file and Medicare rules. In this case, there was insufficient evidence to show that the orders
were individualized based on clinical history and risk assessment. Based on this information, we decided that
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for
the pharmacogenetic testing provided on February 4, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the root canal.
You asked the Plan to pre-approve the root canal. You say that you are in a lot of pain and cannot afford the root canal. The Plan denied your request. The Plan says you do not have jaw or related structure problems that require medical treatment.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the root canal.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on September 4,
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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. 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 drug testing
services provided on September 4, 2019.