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

We decided that the Plan does not have to pay for the train of four testing coded 95999 provided on July 23, 2019.You asked the Plan to pay for the train of four 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 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation supports that train of four testing was completed. This service is included in the cost of the primary procedure (the back surgery). Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met.Therefore, we decided that the Plan does not have to pay for the train of four testing coded 95999 provided on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you can't use a push chair due to arthritis. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the records show that you are currently on home oxygen and had a fall with chronic lower back pain and knee pain. You are on dialysis. The records show that you have a mobility deficit but there is no evidence that the mobility deficit prevents you from accomplishing mobility-related activities of daily living (MRADLs) in the home. There is no evaluation of your gait in the submitted records. There is no evidence that your mobility deficit cannot be helped by an appropriately fitted cane or walker or that you can safely maneuver and operate a PWC. The services are therefore not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on May 7, 2019.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says critical care evaluation and management of the critically ill or critically injured patient, includes evaluation and management services.
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 99232 is not supported in the record. Specifically, critical care evaluation and management of the critically ill or critically injured patient, includes evaluation and management services. The claim submitted does not include the appropriate modifier to indicate that this was a distinct, separately identifiable E/M service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provided on May 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) intra-oral x-rays (D0274) and cleaning (D1110) provided on December 17, 2019.
You asked the Plan to pay for the dental services. You say that you went to this provider and after the services were completed they told you they did not take your insurance and you were not covered. You had to pay $137 out of pocket because you were misinformed. The Plan denied your request. The Plan says the requested services are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The health plan contract says that the plan covers medically necessary dental services as covered by Original Medicare. The services you are asking the Plan to pay for 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 pay for periodic oral exam (D0120) intra-oral x-rays (D0274) and cleaning (D1110) provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 23, 2019 by an out of network (OON) 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 medical services provided on July 23, 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 the injection services provided on November 22, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 injection services provided on November 22,
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the exchange nephrostomy catheter procedure provided on December 30, 2019.
You asked the Plan to waive the copayment for the exchange nephrostomy catheter procedure. You say that it does not make sense for a less invasive procedure to have such a high copayment. You say this procedure is not surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $215 copayment for Medicare-covered outpatient surgery at an in-network outpatient hospital. You have been asked to pay a $215 copayment for the exchange nephrostomy catheter procedure. The exchange nephrostomy catheter procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the exchange nephrostomy catheter procedure is considered a surgical procedure.
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 exchange nephrostomy catheter procedure provided on December 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel to home or nursing home (R0075), elbow x-ray (73070), shoulder x-ray (73030), and set-up of portable x-ray equipment (Q0092) provided on December 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for transportation of portable x-ray equipment and personnel, elbow x-ray, shoulder x-ray, and set-up of portable x-ray equipment. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.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 transportation of portable x-ray equipment and personnel to home or nursing home (R0075), elbow x-ray (73070), shoulder x-ray (73030), and set-up of portable x-ray equipment (Q0092) provided on December 21, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis -adult (D1110), bitewings -four radiographic images (D0274) and periodic oral evaluation -established patient (D0120) provided from November 5, 2018 through November 30, 2018.You asked the Plan to pay for the dental services. You say that the services are covered by your plan and that you should be reimbursed for the dental services.The Plan denied your request. The Plan says the performed services are not covered by either Original Medicare or the health plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for 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.  In 2018, at the time of service, you had coverage for Medicare-covered dental services only.Therefore, we decided that the Plan does not have to pay for prophylaxis -adult (D1110), bitewings -four radiographic images (D0274) and periodic oral evaluation -established patient (D0120) provided from November 5, 2018 through November 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on October 21, 2019.You asked the Plan to pay for the 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 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 15 minutes of intraservice time, patient age 5 years or older.We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status; therefore, the billed service cannot be verified. 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 for the moderate sedation services provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in network benefits for services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve in-network benefits. The Plan denied your request. The Plan says there are no in-network inadequacies.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you receive you are care from a provider who is eligible to provide services under Original Medicare. The requested provider in this case is not a network provider with the Plan. However, you have out-of-network benefits. Your plan contract says that if you use an out-of-network provider, your share of the costs for covered services may be higher. We found no exception that would require the Plan to pre-approve the services using in-network benefits. Therefore, we decided that the Plan does not have to pre-approve in network benefits for services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Colchicine 0.6mg tablet (J8499).You asked the Plan to pre-approve Colchicine 0.6mg tablet. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Colchicine 0.6mg tablet (J8499).Benefits for Colchicine 0.6mg tablet may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenicular nerve ablation.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules saythat 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic bilateral knee pain secondary to osteoarthritis. Genicular nerve blocks and genicular nerve ablation are considered investigational and not medically necessary for the treatment of chronic knee pain. The services are therefore not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvegenicular nerve ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on November 5, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that during your appointment an infection was found under your tooth. You say that the medication that was applied was not something you could go and pick up from a pharmacy as it needed to be implanted by a physician. You also say that you were advised this needed to be covered under your pharmacy benefit. The Plan denied your request. The Plan says the service you received is dental in nature. The Plan also says the localized delivery of antimicrobial agents is not listed as a covered service.
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 localized delivery of antimicrobial agents is not among those covered under this benefit. Additionally, the services you are asking the Plan to pay for 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 pay for the localized delivery of antimicrobial agents (D4381) provided on November 5, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the low dose CT scan provided on December 16, 2019.
You asked the Plan to pay for the LDCT scan. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the LDCT scan, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the low dose CT scan provided on December 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 3, 2019 to November 6, 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 not medically necessary.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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was readmitted to the SNF after a hospitalization for a urinary tract infection. She received oral medications and had stable vital signs. She did not receive, nor did she require, daily skilled therapy services for the dates in question. She had no skilled nursing needs. She did not require skilled nursing on a daily basis. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 3, 2019 to November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cyst removal procedure provided on November 25, 2019.
You asked the Plan to waive the copayment for the cyst removal procedure. You say that you were told the surgery would be covered by your insurance. You say you were not aware or informed there would be a $250 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $250 copayment for in-network outpatient surgery services. You have been asked to pay a $250 copayment for the cyst removal procedure. The cyst removal procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cyst removal procedure provided on November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from October 19, 2019 through October 28, 2019.You asked the Plan to pay foracute 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 hospitalcare have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from October 19, 2019 through October 28, 2019.