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

We decided that the Plan does not have to pay for the lab services provided on July 25, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the lab services provided  on July
25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the arthrocentesis provided on May 28,
2019.
You asked the Plan to reduce the copayment for the arthrocentesis. You say that you have had a $25 copayment
in the past for this service. 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 $295
copayment for Medicare-covered surgery other services provided to you at an outpatient hospital including but
not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $295 copayment for the arthrocentesis. The arthrocentesis falls within the
"Outpatient Surgery and Other Medical 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 reduce the copayment for arthrocentesis
provided on May 28, 2019.
Our decision is only about the May 28, 2019 service. If you have any questions about prior years billing, please
contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E0607), test strips (A4253), lancets
(A4259), calibrator solution (A4256), and a lancing device (A4258) provided on June 7, 2019.
You asked the Plan to pay for a blood glucose monitor, test strips, lancets, calibrator solution, and a lancing
device. You say that these items should be covered. The Plan denied your request. The Plan says the delivery
ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order
number or details to corroborate the delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physicianorder and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the
supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one
another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for
a blood glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a
lancing device (A4258) provided on June 7, 2019.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee's current functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on September 10, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that this should be covered as a routine visit because they did the same tests they normally do. You say you were advised you will need cataract 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 $50 copayment for a medical eye exam. You have been asked to pay a $50 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows you had a decrease in vision and experience a squiggly line when working on the computer. Therefore, your exam is considered medical in nature.
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 medical eye exam provided on September 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
You asked the Plan to pre-approve MRI. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that you do not meet the Medicare criteria for the requested MRI. Our physician reviewer found there are no red flags and there has not been an adequate trial of physical therapy. Therefore, the requested MRI is not medically necessary 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room provided from August
31, 2019 to September 1, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the 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 $50
copayment for each emergency room visit.
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency Care" benefit category. The record shows you received services in the emergency
department.
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 provided from August 31, 2019 to
September 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation rendered on June 20, 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 are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. The provider submitted a claim for procedure code 99254 (inpatient consultation). This code has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the inpatient consultation rendered on June 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a Cranial Nerve Neurostimulator
(64568, C1767, 0466T, C1778).
You asked the Plan to pre-approve implantation of a Cranial Nerve Neurostimulator. You say that the requested
service is necessary. The Plan denied your request. The Plan says the service is not covered by Medicare.
Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Cranial Nerve (Hypoglossal) Stimulation for the
treatment of Obstructive Sleep has been determined to be not reasonable and necessary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of implantation of a Cranial Nerve Neurostimulator have not been met. Therefore, we decided that the
Plan does not have to pre-approve implantation of a Cranial Nerve Neurostimulator (64568, C1767, 0466T,
C1778).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the open treatment and/or reduction of vertebral fracture(s)
and/or dislocation(s) services coded 22325 provided on June 4, 2019.
You asked the Plan to pay for the open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s)
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 22325 is open treatment and/or reduction of vertebral
fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar.
We find that CPT code 22325 is not supported in the medical record. Specifically, the medical records did not
include documentation of an open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), by a
posterior approach, for 1 fractured lumbar vertebra or dislocated segment; therefore, this code cannot be
verified. Based on this information, we decided that Medicare rules for coverage of the open treatment and/or
reduction of vertebral fracture(s) and/or dislocation(s) services have not been met.
Therefore, we decided that the Plan does not have to pay for the open treatment and/or reduction of vertebral
fracture(s) and/or dislocation(s) services coded 22325 provided on June 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 31, 2019 to October 19, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 31, 2019 to October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 29, 2019.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there are multiple in-network providers within 30 miles of the member's residence that could have rendered these 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 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 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by the out of
network provider.
You asked the Plan to pay for eye care services. You say that you are monitoring the progression of the floaters
that the enrollee has in both eyes. The Plan denied your request. The Plan says there is no network deficiency
for these services and alternate network providers were found. The Plan says there is an on-line Medicare site
to verify eligibility.
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 August 29, 2019
by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 15, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 27125 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 27125 is hemiarthroplasty, hip, partial (eg, femoral stem
prosthesis, bipolar arthroplasty).
We find that CPT code 27125 is not supported in the medical record. Specifically, there is no documentation
that a partial hip hemiarthroplasty was completed. 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 surgical services rendered on June 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery provided on August 28,
2019.
You asked the Plan to waive the copayment for the cataract surgery. You say that you should not be
responsible for the copayment because the surgery was unfinished. 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 each Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $250 copayment for the cataract surgery. The cataract surgery falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The medical record shows you were given topical and neuroleptic anesthesia.
Therefore, the surgery will be paid at the full amount.
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 cataract surgery provided on August 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 20, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 29823 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive. We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report does not include sufficient documentation to meet the guidelines that a surgical shoulder arthroscopy was performed. 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 surgical services rendered on February 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decipher Prostate Cancer Assay provided to the enrollee on December 28, 2018.
You asked the Plan to pay for the assay. You say that this should be paid for. The Plan denied your request. The Plan says the enrollee must have achieved an initial PSA nadir.
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 pay for the assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coverage criteria for the Decipher Prostate Cancer Assay, as established by LCD L36343, have not been met in this case. There is no documentation of the enrollee achieving an initial PSA nadir within 120 days of surgery.
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 assay have not been met. Therefore, we decided that the Plan does not have to pay for the Decipher Prostate Cancer Assay provided to the enrollee on December 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on July 24, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 a domiciliary or rest home visit provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide (D9230) provided on August
27, 2019.
You asked the Plan to pay for the dental service. You say that the procedure was not a dental service. You also
say that it was performed in associate with a procedure that was covered by insurance. The Plan denied your
request. The Plan says the inhalation of nitrous oxide is not a covered service.
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. Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide
(D9230) provided on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered on August 6, 2019 to October 25, 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 there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 diabetic supplies rendered on August 6, 2019 to October 25, 2019.