Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Varithena sclerotherapy for the enrollee.
You asked the Plan to pre-approve the procedure. You say that the enrollee can't get the radiofrequency ablation because they wouldn't be able to get through with the catheter. The Plan denied your request. The Plan says that the clinical information does establish medical necessity.
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 the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation satisfactorily demonstrates the medical necessity and appropriateness of the procedure in question. There is satisfactory documentation of activity limitation and of efforts to treat conservatively and efforts to treat other underlying causes of leg pain. There is satisfactory documentation of severe reflux in the territory to be treated and absence of DVT. There is satisfactory documentation of adequate arterial perfusion. There is also satisfactory documentation of the need for an alternative to thermal endovenous ablation due to venous tortuosity. There is no suggestion that the procedure is cosmetic. 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve Varithena sclerotherapy for the enrollee.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on February 18, 2020.
You asked the Plan to pay for the drug testing. 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. We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not support that there was any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on February 18, 2020.
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 cannot be adequately managed in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee has not completed the full course in the hospital.
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 physician reviewer found that the enrollee was admitted to the acute care hospital with heart failure and infected venous stasis ulcers. The enrollee was in the ICU. IV Lasix and antibiotics were being administered. 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. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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. The documentation does not support that an additional 25 or more days of acute care are expected in this case. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99497 provided on January 27, 2020.
You asked the Plan to pay for CPT code 99497. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 99497 is Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. We find that CPT code 99497 is not supported in the medical record. Specifically, CPT code 99497 is a time based code. In order to bill CPT code 99497, the documentation must note that the first 30 minutes were face-to-face with the patient, family member(s), and/or surrogate for advance care planning. The progress note for January 27, 2020 only notes 25 minutes was for advanced care planning. As such, the provided documentation does not support the billing of CPT code 99497. Based on this information, we decided that Medicare rules for coverage of CPT code 99497 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99497 provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory tests and EKG provided on March 3, 2020.
You asked the Plan to waive the cost share for the laboratory tests and EKG. You say that the amount you are being billed should be a part of the wellness visit. The Plan denied your request. The Plan says the cost share 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 $20 copayment for Medicare-covered non-preventive lab services and 20% coinsurance for other diagnostic procedures and tests such as MRIs, PET scans, CT scans, and other nuclear medicine. You have been asked to pay a total of $21.02 for the laboratory tests and EKG.

The laboratory tests and EKG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 cost share for the laboratory tests and EKG provided on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 30, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on May 16, 2019. You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy should be considered preventive because you are having the polyps removed so they don't turn cancerous. 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 $225 copayment for Medicare-covered outpatient surgery at an in-network ambulatory surgical center. You have been asked to pay a $225 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows a preoperative and postoperative diagnosis of polyp of cecum. 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 colonoscopy provided on May 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interstitial brachytherapy with permanent seed implantation for breast cancer treatment. You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary due to narrow margins. 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 treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary in this case. Our physician reviewer found the technique requested in this case is not endorsed by any consensus guidelines, societies or cooperative groups. The limited data on its use described outcomes in individuals with wider margins. This would not be furnished in accordance with accepted standards of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve interstitial brachytherapy with permanent seed implantation for breast cancer treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on January 28, 2020.You asked the Plan to waive the copayment for the EKG. You say that you did not want or need an EKG. You say you should not have to pay for it. 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 $150 copayment per visit for all other services furnished at a hospital outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $150 copayment for the EKG.You have been asked to pay a $52.15 copayment for the EKG. The EKG falls within the "Outpatient surgery, including 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 waive the copayment for the EKG provided on January 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging provided on February 19, 2020. You asked the Plan to waive the cost share for the myocardial perfusion imaging. You say that you were under the impression that the government would help out during this time. The Plan denied your request. The Plan says the cost share applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Your contract with the Plan also says that you must pay a $200 copayment after the deductible is met for each advanced imaging service. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to diagnostic imaging. This cost sharing is a contractual obligation that had not been met at the time the myocardial perfusion imaging was received on February 19, 2020. Therefore, $593.71 has been applied to meet your deductible. Since your $750 deductible has been met, you have also been asked to pay the $200 copayment. 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 cost share for the myocardial perfusion imaging provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the walker with wheels purchased on February 9, 2020.You asked the Plan to reimburse you for the walker with wheels. You say that you thought this walker would be entitled to reimbursement from your allowance for over the counter goods.The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Durable medical equipment purchased privately through the internet, or by private purchase are not eligible for coverage by your Medicare governed health plan.Also, walkers are not listed in the Plan's 2020 Over-The-Counter Catalog. Therefore, we decided that the Plan does not have to reimburse you for the walker with wheels purchased on February 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on October 8, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that the facility could not run further tests on you. You say that you are being unjustly penalized. 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 $120 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated during the ER visit. 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 ER visit provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on April 21, 2020.
You asked the Plan to waive the copayment for the specialist visit. You say that you were in the hospital for an observation stay. You say that this should be covered under the observation copayment. 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 $35 copayment for each specialist visit. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist visit provided on April 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour Next Monitor Kit with device.You asked the Plan to pre-approve the services. You say that this is medically necessary, as it is hard to use the OneTouch.The Plan denied your request. The Plan says there was no clinical reason that the enrollee could not use preferred product.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific clinical rationale for the requested Contour Next Monitor Kit with device. There was no clinical reason that the enrollee could not use preferred product. The requested Contour Next Monitor Kit with device is not medically necessary or reasonable.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-approvethe Contour Next Monitor Kit with device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic x-ray (D0330) and excision of benign lesion (D7410) provided February 14, 2020.
You asked the Plan to pay for the dental services. You say that after a visit with your regular dentist you were referred to a specialist. You assumed it was all within the approved provider list and insurance coverage. The Plan denied your request. The Plan says enrollee's must receive dental services from an in-network dental provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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. The health plan contract specifically says covered benefits are covered only when provided by a participating dentist or when appropriate and necessary as determined by the standards of generally accepted dental practice and the Plan. All comprehensive dental care is subject to prior authorization, which means your dentist must first submit a request for authorization to the Plan to determine if the services are covered. 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 for panoramic x-ray (D0330) and excision of benign lesion (D7410) provided February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 2, 2020 to January 10, 2020.You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim denied appropriately per Medicare guidelines. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.The documentation in the case file does not show that the provider at issue is eligible to provide services under Original Medicare. 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 January 2, 2020 to January 10, 2020.