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

We decided that the Plan does not have to pay for intraoperative neurophysiologic monitoring (95868, 95870, 95927, 95938) provided on November 18, 2020.
You asked the Plan to pay for intraoperative neurophysiologic monitoring. You say that this was medically necessary and billed correctly. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. We looked at the file and Medicare rules. The services at issue were billed with the Mobile Unit POS code 15,
but the records show that the mobile unit was serving an entity for which another POS code already exists.
Based on this information, we decided that Medicare rules for coverage of intraoperative neurophysiologic
monitoring have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative
neurophysiologic monitoring (95868, 95870, 95927, 95938) provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 1, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $35 copayment for physician/practitioner services/specialty physician office. 

You have been asked to pay a $35 copayment for a specialist office visit. The correct copayment has been applied to the specialist services that were provided. A specialist office visit falls within the physician/practitioner services/specialty physician office 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 a specialist office visit provided by a participating provider on March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spine x-ray provided on March 22, 2021.
You asked the Plan to waive the copayment for the spine x-ray (72100). You say that you have never had to pay this kind of a balance for x-rays. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $100 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $100 copayment for the spine x-ray (72100). The spine x-ray (72100) falls within the Outpatient Diagnostic Tests 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 spine x-ray provided on March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest.

You asked the Plan to pre-approve these 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 say that CT scans are covered only when they are medically necessary. 

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 had a chest x-ray and chest CT without contrast that did not demonstrate evidence of a lung lesion but did reveal a three centimeter right thyroid lobe nodule. The records do not support that the requested CT scan is reasonable or 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 computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endocrinology consultation and treatment for cardiovascular risk reduction to be provided by a tertiary-level facility.
You asked the Plan to pre-approve the tertiary-level endocrinology services. You say that you feel that this should be approved so you can have all your care provided in the same place. The Plan denied your request. The Plan says there are other network providers at a non-tertiary level of care who can furnish the necessary services.
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 tertiary-level endocrinology services. Our reviewer says that the requested tertiary provider is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 33-year-old female with diabetes, obesity, lymphedema and history of breast cancer for whom weight loss is recommended prior to having breast reconstruction surgery. Referral to a tertiary endocrinology specialist has been requested. At issue in this case is whether a tertiary endocrinology specialist is medically necessary as opposed to a non-tertiary endocrinology
specialist for assistance with the enrollee's weight loss and cardiovascular risk reduction prior to surgery. Based on the medical records provided, there is no documentation to support that appropriate weight loss management and cardiovascular risk reduction prior to surgery can only be provided by the tertiary endocrinology specialist. Nothing in the record documents that non-tertiary providers cannot furnish this treatment. 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 tertiary-level endocrinology services have not been met. Therefore, we decided that the Plan does not have to pre-approve endocrinology consultation and treatment for cardiovascular risk reduction to be provided by a tertiary-level facility.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on September 4, 2020.

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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation
(A0428 x2, A0425 x2) provided on April 29, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that the
service was necessary. The Plan denied your request. The Plan says the copayment applied correctly.

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 $290
copayment per date of service regardless of the number of trips for ambulance services.

You have been asked to pay a $290 copayment for non-emergency ambulance transportation. The services at
issue fall within the ambulance services 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 non-emergency ambulance transportation (A0428 x2,
A0425 x2) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397), provided on November 2, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items were medically necessary. The Plan denied your request. The Plan says the items were ordered through an unsolicited telephone call.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397), provided on November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (68340, 68326) provided on February 8,
2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were out-of-network, non-emergent and not preauthorized.

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 services at issue in this appeal. The Plan did not pre-approve the 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 surgical services (68340, 68326) provided on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for
you. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested
level of care is not medically necessary.

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 the complexity of your nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is
no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on January 7, 2020.

You asked the Plan to pay for therapeutic exercises. The Plan denied your request. The Plan says the Plan
received insufficient documentation to corroborate the services to confirm Medicare coverage has been met.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of
therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on January 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a non-participating provider on February 15, 2021.

You asked the Plan to waive the copayment for an ultrasound. You say that this should be processed as in-network. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. 

You have been asked to pay $87.24 which is less than your copayment amount of $110 for an ultrasound. Even though this provider is out-of-network, the Plan has processed this claim as a participating provider; therefore, the correct copayment has been applied. Ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services 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 ultrasound provided by a non-participating provider on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a general dentistry visit to be provided by an OON provider.

You asked the Plan to pre-approve a general dentistry visit. You say that the closest dentist is too far away. The Plan denied your request. The Plan says there are providers in your area who can perform the general dentistry services.

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 contract also says that dental services are only covered when received by a participating provider.

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 general dentistry visit to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on July 6, 2020.

You asked the Plan to waive the copayment for the outpatient surgery. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgical services in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 Medicare-covered surgical services in an outpatient hospital setting. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you had outpatient surgical services in an outpatient hospital setting on July 6, 2020. You have been asked to pay a $250 copayment for the outpatient surgery. The outpatient surgery falls within the Outpatient hospital services 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 outpatient surgery provided on July 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020.

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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 prothrombin, coagulation factor II (81240).

You asked the Plan to pre-approve the F2 prothrombin, coagulation factor II. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says the enrollee is not displaying any clinical features of an associated disease to factor II deficiency and the result of this test will not directly impact her treatment.

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 F2 prothrombin, coagulation factor II. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no pedigree is provided of which relatives to decide how likely it is that the member would be impacted. In addition, given she is in her 70s and has had two major surgeries without bleeding makes the likelihood that she has this mutation very low. 

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 F2 prothrombin, coagulation factor II have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 prothrombin, coagulation factor II (81240).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received November 10, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan should cover the cost of the copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 Ambulance Services. 

You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services 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 ambulance transportation (A0427) received November 10, 2020.