Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1851) provided to the enrollee on April 3, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1851) provided to the enrollee on April 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health aide services for a total of 14 hours per week.
You asked the Plan to pre-approve additional home health aide services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 additional home health aide services. Our reviewer says that the documentation does not support that the requested home health aide services are medically reasonable or necessary. Our physician reviewer found the documentation supports that you have no pressure ulcers, stasis wounds, or surgical wounds. There are no respiratory problems noted unless with moderate exertion. You do not have complex wound care, new enteral feeds, or a new tracheostomy tube. The request for the remaining 7 hours a week of home health aide services is not medically necessary to the treatment of your illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health aide services for a total of 14 hours per week.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forrotary wing air transport (A0431) rotary wing mileage (A0436) provided June 14, 2019.You asked the Plan to pay forthe rotary wing air transport. You say that you believe that The Plan, as the secondary payer, is responsible for the 20%co-payment amount.The Plan denied your request. The Plan says that the primary carrier's payment is higher than the Medicare allowable fee maximum.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 $42,748.55 minus the primary payment of $5099.80 = $201.91. Therefore, we decided that the plan, has to pay the secondary payment in the amount of $201.91.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has been in the ICU for a long time and needs the specialized care able to be offered in an LTACH setting. The Plan denied your request. The Plan says an LTACH is not able to provide any clinically superior service to those available at the current facility.
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support including, surveillance laboratory studies, telemetry wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a comprehensive electrophysiologic evaluation provided from May 31, 2019 to June 1, 2019.
You asked the Plan to waive the coinsurance for a comprehensive electrophysiologic evaluation. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance outpatient diagnostic tests. You have been asked to pay $3,708.33, which is less than the 20% coinsurance amount for a comprehensive electrophysiologic evaluation. A comprehensive electrophysiologic evaluation falls within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for a comprehensive electrophysiologic evaluation provided from May 31, 2019 to June 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (HCPCS G0483) provided to the enrollee on March 22, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe documentation received does not include definitive laboratory results for 22 or more drug classes to support the coding criteria for code G0483.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of  HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the available documentation in the case file does not support the coding of HCPCS G0483 as medically reasonable and 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services (HCPCS G0483) provided to the enrollee on March 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213).
You asked the Plan to pre-approve the dental service. You say that the enrollee had an existing prior authorization for an upper and lower that has expired. You say that the enrollee needs a new prior authorization. You say that the request was denied despite the enrollee still having the same plan. The Plan denied your request. The Plan says partial dentures are 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, partial dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a cranial (hypoglossal) nerve neurostimulator (0466T).
You asked the Plan to pre-approve these services. You say that continuous positive airway pressure have failed to work for you. The Plan denied your request. The Plan says that this is not considered reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that insertion of a chest wall respiratory sensor with procedure code 0466T is not considered medically reasonable and necessary at this time and is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve implantation of a cranial (hypoglossal) nerve neurostimulator (0466T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for plastic surgery services (CPT 64856 and CPT 20926) provided to the enrollee on August 12, 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 the denied codes are not supported in the medical records submitted.
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 the denied codes is: CPT 64856: Suture of major peripheral nerve, arm or leg, except sciatic; including transposition CPT 20926: Tissue grafts, other (eg, paratenon, fat, dermis) We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found procedure code 64856 is not supported by the operative report. While the operative report did document that a large dorsal nerve was found and was placed into a regenerative peripheral nerve interface muscle bed for a muscle from the distal abductor digiti minimi muscle, it did not include documentation of a suture of a major peripheral nerve of the arm or leg, except for the sciatic nerve, including transposition. Consequently, the coding of CPT 64856 cannot be verified. Procedure code 20926 is not supported by the operative. There was not documentation of tissue grafts, other (paratenon, fat and dermis). Consequently, the coding of CPT 20926 cannot be verified. 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 pay for plastic surgery services (CPT 64856 and CPT 20926) provided to the enrollee on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for miscellaneous supply or accessory for use with an implanted ventricular assist device (CPT Code Q0508) provided to the enrollee on September 13, 2019.
You asked the Plan to pay for the DME. You say that these are sterile dressings and cannot be reused. You state the patient will need these supplies monthly until he receives a heart transplant. The Plan denied your request. The Plan says that this code cannot be billed more than one (1) unit per year.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have been met. The MUE for CPT Code Q0509 is 24 which means that up to 24 units per date of service can be billed. There is no indication that only one unit is covered per year, and that this directly contradicts the Plan's authorization which approved 12 units of the code over the 12 month period. Therefore, we decided that the Plan has to pay for miscellaneous supply or accessory for use with an implanted ventricular assist device (CPT Code Q0508) provided to the enrollee on September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient hospital care provided from September 2, 2019 to September 6, 2019.
You asked the Plan to waive the copayment. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says you are responsible to pay a $200 copayment for acute inpatient hospital care services provided per your contractual policy.
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 $200 copayment each time you are admitted into an acute care hospital. You will not pay more than $400 for inpatient hospital covered services in a calendar year. You have been asked to pay a $200 copayment for the acute inpatient hospital care 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 acute inpatient hospital care provided September 2, 2019 to September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on October 30, 2018.
You asked the Plan to pay for the ABPM. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ABPM have not been met. The ambulatory blood pressure monitor (ABPM) is only covered for suspected white coat hypertension, and must be performed for at least 24 hours to meet coverage criteria. Suspected white coat hypertension is defined as 1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 2. At least two documented blood pressure measurements taken outside the office which are <140/90mm Hg; and 3. No evidence of end-organ damage. ABPM is not covered for any other uses. This would be included in the payment for the ambulance service. Therefore, we decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on October 30, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays (D0274), the initial intraoral x-ray (D0220), the additional intraoral x-ray (D0230), and the topical application of fluoride varnish (D1208) provided on August 9, 2019.You asked the Plan to pay forthe dental services. You say that you needed the services because you have diabetes. You also say that you do not have money to pay for the dental services.The Plan denied your request. The Plan says the application of fluoride varnish is not a covered service. The Plan also says that the frequency limit of 2 x-rays per calendar year has been exceeded.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 and x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the initial and additional periapical x-rays that youreceived on August 5, 2019. Additionally, the application of fluoride varnish is not a covered service.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays (D0274), the initial intraoral x-ray (D0220), the additional intraoral x-ray (D0230), and the topical application of fluoride varnish (D1208) provided on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 14, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the medical records do not support the services.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Documentation submitted did not include a valid physician order, Proof of Delivery, or a Delivery Ticket. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSPECT test provided on August 28, 2019.You asked the Plan to waive the copayment forthe SPECT test. You say that you would like to appeal your 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 $200 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $200 copayment for the SPECT test. The SPECT test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 forthe SPECT test provided on August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe T3 SR Capsules provided from July 16, 2019 to September 4, 2019.You asked the Plan to pay forthe drugs. The Plan denied your request. The Plan says that this is not a covered Part B drug.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 pay forthe T3 SR Capsules provided from July 16, 2019 to September 4, 2019.Benefits for the drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora general health panel provided on September 10, 2019.You asked the Plan to pay forgeneral health panel. You say that your facility is a reference laboratory, and you processed the specimen sent by the ordering physician.The Plandenied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that procedure code 80050 is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of general health panel have not been met.Therefore, we decided that the Plan does not have to pay fora general health panel provided on September 10, 2019.