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

We decided that the Plan does not have topay for the services (CPT 72125, CPT 70450) provided. You asked the Plan to pay forthe services. The Plan denied your request. The Plan says when a patient is in a registered inpatient status,all services reported by all providers should reflect and acknowledge the patient's inpatient status.The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital inpatients or outpatients, the inpatient or outpatient hospital POS code is tobe reported regardless of where the face-to-face service takes placeWe looked at the file and Medicare rules. At the time the services in question were provided, the enrollee in this case was an inpatient. This means thatthe services provided must be reported with inpatient POS code 21. The services were billed with POS code 23. Based on this information, we decided that Medicare rules for coverage of the serviceshave not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 72125, CPT 70450) provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from June 1, 2019 to June 30, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that the plan should pay this. The Plan denied your request. The Plan says that these charges are your responsibility.
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 $25 copayment per day for days 21-100 for Medicare-covered stays at a SNF. You have been asked to pay $750 for the SNF services. The file shows you were in a SNF from May 1, 2019 through May 6, 2019 and May 15, 2019 through July 17, 2019. The SNF services from June 1, 2019 through June 30, 2019 fall within the days 21-100 for Medicare-covered stays at a SNF 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 skilled nursing facility (SNF) services provided from June 1, 2019 to June 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says the records provided do not establish that the MRI is 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 the MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there is no history of location or duration of pain. There is no documentation of trial of conservative therapy. There are no focal neurologic deficits documented. There are no red flags on physical examination. An MRI is not indicated 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admission for L2-3 decompression for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the procedures can be performed on an ambulatory/observation basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the laminectomy surgery may be performed safely as an outpatient or observational level stay. Inpatient admission is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient admission for L2-3 decompression for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits and x-ray provided on April 3, 2019, May 24, 2019, May 25, 2019 and June 5, 2019.
You asked the Plan to waive the copayments for the office visits and x-ray. You submitted your bill for review. You say that you were in the hospital and want insurance to pay this bill. The Plan denied your request. The Plan says the copayments 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 $50 copayment for services obtained from an in-network specialist and a $7 copayment for each Medicare-covered standard x-ray service from an in-network provider. You have been asked to pay a $50 copayment for each office visit and a $7 copayment for the x-ray. The total amount you owe is $157 ($50 + $50 +$50 +$7 = $157). The office visits fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The x-ray 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 copayments for the office visits and x-ray provided on April 3, 2019, May 24, 2019, May 25, 2019 and June 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2019 to July 26, 2019 by the out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 2, 2019 to July 26, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for chemotherapy administration services provided to the enrollee on July 22, 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 that the denied codes remain 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 the denied codes is: CPT 94613: chemotherapy administration, intravenous infusion technique; single or initial substance/drug was performed up to 1 hour CPT 96375: therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug CPT 96417: chemotherapy administration, intravenous infusion technique; single or initial substance/drug was performed up to 1 hour HCPCS J1100: Injection, dexamethasone sodium phosphate, 1 mg HCPCS J9267: Injection, paclitaxel, 1 mg 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 reviewers says that the services at issue in this were coded correctly. Our physician reviewer found the additional documentation submitted by the appellant supports the codes in question. The medication administration record contains evidence of a paclitaxel infusion over 2 hours and an IV push administration of benadryl and famotidine, performed on the date of service in question.
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 been met. Therefore, we decided that the Plan has to pay for chemotherapy administration services provided to the enrollee on July 22, 2019.
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve adhesive remover wipes (A4456)
You asked the Plan to pre-approve adhesive remover wipes. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that there is no indication that the requested item is considered reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 adhesive remover wipes. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found adhesive remover wipes are medically reasonable and necessary for patients with a urinostomy. The urinostomy are attached to the skin with adhesives that must be removed when the appliances are changed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of adhesive remover wipes have been met. Therefore, we decided that the Plan has to pre-approve adhesive remover wipes (A4456)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires medical oversight, frequent lab
work, and an intensive interdisciplinary team approach to rehab care. The Plan denied your request. The Plan
says the enrollee does not require 3 hours of rehab a day, or specialized equipment.
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 physician reviewer found
that the enrollee's medical conditions appear stable. There is no complex wound care needs. He is currently in
an outpatient setting, and does not require any acute hospital level of care. The enrollee requires physical
therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment.
However, there is no reported significant new injury or reversible impairing condition. He has a limited level of
function, and does not require an intensive rehabilitation therapy program. The member is limited by debility
and the severity of his comorbid medical conditions. He would not be expected to be able to fully participate in
or benefit from the required intensity of an acute rehabilitation therapy program.
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation devices (HFCWODs) (E0483) to be provided by out of network provider
You asked the Plan to pre-approve the HFCWOD. You say that you are requesting an in network exception The Plan denied your request. The Plan says enrollee's must receive their DME supplies from an in-network provider. The plan has confirmed that there are 2 in-network providers that can provide the requested service.
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 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. 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 the high frequency chest wall oscillation devices (HFCWODs) (E0483) to be provided by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 20, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that it takes a half hour to an hour to set up the heart-lung machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite (code D2391) provided on September 26, 2019.You asked the Plan to pay forthe resin-based composite. You say that you asked prior to having this service provided and weretold it would be covered by your insurance.The Plan denied your request. The Plan says this service is not covered by the Plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe resin-based composite (code D2391) provided on September 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anterior apicoectomy provided on August 8, 2019.
You asked the Plan to pay for the apicoectomy. You say that this was a drill through your gums, not your teeth, to correct an infection under two teeth. You also say that this was a medical issue and not a dental issue. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed for this type of service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers an allowance benefit of $225 every year for Non-Medicare covered preventive and comprehensive dental services. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual allowance benefit on May 29, 2019 and your annual deductible benefit has been exhausted. The record also shows that the Plan paid you in excess of the $225 dental allowance for services rendered on May 29, 2019. Therefore, we decided that the Plan does not have to pay for the anterior apicoectomy provided on August 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTraumaplant Comfrey Cream.You asked the Plan to pre-approveTraumaplant Comfrey Cream. The Plan denied your request. The Plan says this is not FDA approved.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Traumaplant Comfrey Cream. Our reviewer says that Traumaplant Comfrey Cream is not medically reasonable and necessary. Our physician reviewer found Traumaplant Comfrey Cream is not an FDA-approved product which has clinically demonstrated efficacy for the enrollee's condition. The documentation does not support that the Traumaplant Comfrey Cream is safe and effective for the enrollee in this case.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Traumaplant Comfrey Cream have not been met.Therefore, we decided that the Plan does not have to pre-approveTraumaplant Comfrey Cream.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve polysomnography (95810).
You asked the Plan to pre-approve polysomnography. You say that this is medically necessary. The Plan denied your request. The Plan says that a sleep study is not necessary because the enrollee has already been diagnosed with obstructive sleep apnea.
The Plan must follow Medicare rules. Medicare rules say that polysomnography (95810) is considered medically reasonable and necessary for the above listed diagnoses. 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 polysomnography. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a high suspicion of having obstructive sleep apnea (OSA) based on his complex symptoms. The patient has been on continuous positive airway pressure (CPAP), which appears to have been prescribed empirically. Two home polysomnography (PSG) tests on consecutive nights were unable to confirm OSA. Therefore an attended, in-lab diagnostic PSG is considered reasonable and 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 polysomnography have been met. Therefore, we decided that the Plan has to pre-approve polysomnography (95810).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services 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.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on May 14, 2019, and June 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 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 forthe medical services provided to you by an out-of-network provider on May 14, 2019, and June 20, 2019