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

We decided that the Plan does not have to pay for an autonomic nervous system function test (code 95923) provided to the enrollee on July 26, 2021.
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says an autonomic nervous system function test (code 95923) may not be reported when an automated device is used to perform the test.
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 95923 is "Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential." We asked our coder 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 test. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation does not include description of this procedure, and therefore cannot be confirmed.
The results are documented as "Sudomotor Function skin response evaluation indicated mild dysfunction of the sweat glands indication mild small fiber peripheral neuropathy in feet. Printout of results can be produced as needed." QSART consists of applying a small electric current and chemical called acetylcholine to the skin. Sweat glands are stimulated and a capsule placed on the skin captures the sweat that is measured by the machine. This procedure 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 test have not been met. Therefore, we decided that the Plan does not have to pay for an autonomic nervous system function test (code 95923) provided to the enrollee on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedure codes 70450 and 99503) provided to the enrollee on August 9, 2021.
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 the services were coded properly.
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Additionally, CPT 99053 has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (procedure codes 70450 and 99503) provided to the enrollee on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on August 16, 2021.
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 type of provider is not covered.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory services provided on September 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit and lab services. You say that this provider is your primary care group. 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 authorization was not 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 had network providers
available who could have provided 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 an office visit and laboratory services provided on
September 30, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a TDAP vaccine provided on September 22, 2021.
You asked the Plan to pay for this vaccine under Medicare Part B. You say that this vaccine should be covered by the Plan. The Plan denied your request. The Plan says this vaccine is covered under Medicare Part D.
The Plan is correct in this case. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide this vaccine under Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to this vaccine under Medicare Part B. This vaccine was given as a preventative service. Therefore, we decided that the Plan does not have to pay for a TDAP vaccine provided on September 22, 2021. Benefits for this vaccine under Medicare Part B. 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 pay for anesthesia services (99100) provided July 30, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for separate payment.
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 99100 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "B". Payment is always bundled with payment for another service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (83036, 84153) rendered by the out-of-network (OON) provider on August 4, 2021.
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services (83036, 84153) rendered by the out-of-network (OON) provider on August 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99283) provided on April 26, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care services provided in an emergency room. You have been asked to pay a $120 copayment for the emergency room visit provided. 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 emergency room visit (99283) provided on April 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Ideal Protein personal meals provided from April 26, 2021, to August 18, 2021.
You asked the Plan to reimburse you for the personal dietary meals. You say that this diet meal plan is the only die that has worked for you. You also say that this program may save your life and save thousands of dollars in health care costs. The Plan denied your request. The Plan says the personal dietary meals are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal dietary meals have not been met. Specifically, the file shows that personal dietary meals are not covered by the Plan or Medicare. Therefore, we decided that the Plan does not have to reimburse you for the Ideal Protein personal meals provided from April 26, 2021, to August 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital evaluation and management (E&M) visit provided on April 5, 2021.
You asked the Plan to pay for hospital E&M visit. You say that this service was not included in another procedure. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because code 99232 should be denied when there is a claim on the same day or the day after with a surgery code.
The Plan must follow Medicare rules. Medicare rules say that E&M services are generally not payable on the same day or during the 10-day postoperative period of surgical code 10061. We looked at the file and Medicare rules. This E&M visit was performed on April 5, 2021. Surgical code 10061 was performed on date of service April 6, 2021. Therefore, this E&M visit was not billed on the same day of the procedure or during the 10-day postoperative period of code 10061 and therefore it is not excluded from separate payment. Based on this information, we decided that Medicare rules for coverage of hospital E&M visit have been met. Therefore, we decided that the Plan has to pay for subsequent hospital evaluation and management (E&M) visit provided on April 5, 2021.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on June 6, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you returned to the emergency room only an hour and a half after leaving from your first visit. 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 $60 copayment for each emergency room visit.
The record shows you were discharged from the emergency room and returned for the same condition. These are considered separate visits. Therefore, you have been asked to pay a $60 copayment for ER visit. ER visits fall within the Emergency Care 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 an emergency room (ER) visit provided on June 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on June 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to reimburse you for hearing aids. You say that you were unaware that you had to see a Plan network provider for your hearing aids. You also say the Plan declined to advise you of this and had they advised you of this in August, you could have returned the hearing aids and go through the correct process with the Plan for hearing aids. Now you are unable to return the hearing aids and you would like the Plan to reimburse you the allowed amount. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an OON provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider.
We looked at the file and the Plan's rules. The records show that you did not receive hearing aids from the Plan's specific required provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5261) provided on June 8, 2021, by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 20, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were told that you would not receive a bill for this service because you were not transported to the hospital. You also say that the paramedics did not take your insurance information and you believed you would not be billed. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on August 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve in-network coverage for an out of plan referral for excision (surgical removal) of a basal cell cancer on the right forearm, to be provided by an out-of-network provider.
You asked the Plan to pre-approve the service. You say that you have had cancer surgery three or four times in the past with this doctor. The Plan denied your request. The Plan says this service can be provided by an in-network provider.
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. 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 in-network coverage for an out of plan referral for excision (surgical removal) of a basal cell cancer on the right forearm, to be provided by an out-of-network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of admission to a skilled nursing facility
(SNF) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says daily skilled services are no longer required, and the continuation of services is 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 in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found based on the medical records provided,
there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill,
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide
medically necessary and reasonable treatment. Daily skilled services are not required. The enrollee does not
require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or an
assisted living facility with home health care or in a long-term care facility on a part time basis appear
appropriate in this case.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continuation of admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an angiogram to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you would like to stay with the out of network provider. The Plan denied your request. The Plan says that elective out-of-network care is not a benefit of 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 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.
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 an angiogram to be provided by an out-of-network (OON) provider